
Class 

Book_ 






I /-I 



Copyright^! . 



COPYRIGHT DEPOSIT. 



A TEXT-BOOK 



OF 



DISEASES OF WOMEN 



BY 



CHARLES B* PENROSE, M.D., Ph.D. 

Formerly Professor of Gynecology in the University of Pennsylvania! 
Surgeon to the Gynecean Hospital, Philadelphia 



TOitb 225 ITllustrations 



SIXTH EDITION, REVISED 



PHILADELPHIA AND LONDON 

W. B. SAUNDERS COMPANY 

J908 



-^ 






LIBRARY of CONGRESS* 
I wo Copies rtece.,..* 

SEP 9 ( 1*W 

OLAS* CL Uto. no. 
COPY B. 



Set up, electrotyped, printed, and copyrighted July, 1897. Revised, reprinted, 

and recopyrighted May, 1898. Reprinted December, 1899. Revised, 

reprinted, and recopyrighted December, 1900. Revised, reprinted, 

and recopyrighted July, 1901. Reprinted January, 1902. 

Revised, reprinted, and recopyrighted, June, 1904. 

Reprinted August, 1905. Revised, reprinted, 

and recopyrighted March, 1908. 



Copyright, 1908, by W. B. Saunders Company. 



PRINTED IN AMERICA 



PRESS OF 

W. B. SAUNDERS COMPANY 

PHILADELPHIA 



PREFACE TO THE SIXTH EDITION. 



I have carefully revised this book for the sixth 
edition, and have made those changes and additions 
that have been rendered necessary by the increase of 
our knowledge of gynecology. 

CHARLES B. PENROSE. 

1720 Spruce Street, Philadelphia. 
March, 1908. 



PREFACE. 



I HAVE written this book for the medical student. I 
have attempted to present the best teaching of modern 
gynecology, untrammelled by antiquated theories or 
methods of treatment. I have, in most instances, recom- 
mended but one plan of treatment for each disease, hop- 
ing in this way to avoid confusing the student or the 
physician who consults the book for practical guidance. 
I have, as a rule, omitted all facts of anatomy, phys- 
iology, and pathology which may be found in the gen- 
eral text-books upon these subjects. Such facts have 
been mentioned in detail only when it seemed important 
for the elucidation of the subject, or when there were 
certain points in the pathology that were peculiar to the 
diseases under consideration. I am indebted to Dr. H. 
D. Beyea for several pathological drawings, and to Dr. 
Wm. R. Nicholson for the preparation of the Index. 

CHAS. B. PENROSE. 



CONTENTS. 



CHAPTER I. 

PAGE 

The; General Causes of Diseases of Women 15 

CHAPTER H. 
Methods of Examination 19 

Examination of the Abdomen, 19. — Examination of the External 
Genitals and Pelvic Structures, 22. — Vaginal and Bimanual Examina- 
tion, 23. — Examination of the Rectum, 33. — Examination of the 
Bladder, 34. — Antisepsis, 35. 

CHAPTER HI. 
Diseases of the External Genitals 36 

Vulvitis, 36. — Inflammation of the Vulvo-vaginal Glands, 38. — Sup- 
puration of the Vulvo-vaginal Gland, 39. — Cysts of the Vulvo-vaginal 
Glands, 40. — Pruritus Vulvae, 42. — Kraurosis Vulvae, 44. — Varicose 
Tumors of the Vulva, 46. — Hematoma of the Vulva, 46. — Papilloma 
46. — Elephantiasis, 47. — Adhesions of the Clitoris, 48. 

CHAPTER IV. 
Diseases of the Vagina 49 

Inflammation of the Vagina, 49. — Tumors of the Vagina, 51. — 
Atresia of the Vagina, 52. — Vaginismus, 53. — Coccygodynia, 54. 

CHAPTER V. 
Anatomy and Mechanism of the Perineum 56 

CHAPTER VI. 

Injuries to the Perineum 62 

Slight Median Laceration of the Perineum, 67 — Median Tear in- 
volving the Sphincter Ani, 68. — Laceration through the Sphincter Ani. 
involving the Recto-vaginal Septum, 73. — Laceration in One or Both 
Vaginal Sulci, 75. — Subcutaneous Laceration of the Muscles and Fas- 
cia, 85. 

9 



io CONTENTS. 

CHAPTER VII. 

PAGE 

Results of Laceration of the Perineum 87 

Rectocele, 87. — Cystocele, 88. — Enterocele, 91. — Subinvolution of 
the Vagina, 92. 

CHAPTER VIII. 
The Position of the Uterus and the Mechanism of its 
Support 94 

CHAPTER IX. 
Prolapse of the Uterus 101 

CHAPTER X. 
Anteflexion of the Uterus 119 

CHAPTER XI. 
Retroflexion and Retroversion of the Uterus . . . .127 

CHAPTER XII. 

IvACERATlON OF THE CERVIX UTERI 1 48 

CHAPTER XIII. 
Inflammation of the Cervical Mucous Membrane (Cer- 
vical Catarrh) 166 

CHAPTER XIV. 
Congenital Erosion and Split of the Cervix 174 

CHAPTER XV. 
Cervical Polypi ; Hypertrophic Elongation of the 
Cervix ; Chancre of the Cervix ; Tuberculosis of 
the Cervix 178 

Cervical Polypi, 178. — Hypertrophic Elongation of the Vaginal Cer- 
vix, 178. — Chancre of the Cervix, 180. — Tuberculosis of the Cervix, 
180. 

CHAPTER XVI. 
Cancer of the Cervix Uteri 181 

CHAPTER XVII. 
Diseases of the Body of the Uterus 199 

Acute Corporeal Endometritis, 199. — Chronic Corporeal Endome- 
tritis, 201. — Exfoliative Endometritis, or Membranous Dysmenorrhea, 
212.— Senile Endometritis, 213. 



CONTENTS. 1 1 

CHAPTER XVIII. 

PAGE 

Subinvolution of the Uterus ; Superinvolution of the 
Uterus 215 

CHAPTER XIX. 
Cancer and Sarcoma of the Uterus 218 

Cancer of the Body of the Uterus, 218. — Malignant Adenoma, 221. 
— Sarcoma of the Uterus, 225. — Diffuse Sarcoma of the Mucous Mem- 
brane, 225. — Sarcoma of the Uterine Parenchyma, 227. — Chorio- 
epithelioma or Syncytioma Malignum, 228. 

CHAPTER XX. 
Fibroid Tumors of the Uterus . 230 

Adenomyoma of Uterus, 257. 

CHAPTER XXI. 
Hematometra ; Hydrometra ; Pyometra 259 

CHAPTER XXII. 
Tuberculosis of the Uterus 261 

CHAPTER XXIII. 
Inversion of the Uterus 264 

CHAPTER XXIV. 
Diseases of the Fallopian Tubes 272 

Inflammation of the Fallopian Tubes, or Salpingitis, 276. — Acute 
Salpingitis, 277. — Chronic Salpingitis, 279. — Suppuration of the Pelvic 
Cellular Tissue, 303. 

CHAPTER XXV. 

Diseases of the Fallopian Tubes [Continued) 306 

Tuberculosis, 306. — Adenoma, Myoma, Cancer, Sarcoma, Actino- 
mycosis, and Syphilitic Gummata of the Fallopian Tubes, 313. 

CHAPTER XXVI. 
Tubal Pregnancy 314 

Ovarian Pregnancy, 329. 

CHAPTER XXVII. 
Diseases of the Ovaries 130 



12 CONTENTS. 

CHAPTER XXVIII. 

PAGE 

Diseases of the Ovaries (Continued) 334 

Hernia of the Ovary, 334. — Prolapse of the Ovary, 335. — Inflam- 
mation of the Ovary, Oophoritis, or Ovaritis, 339. — Acute OSphoritis, 
339. — Chronic Oophoritis, 341. — Apoplexy of the Ovary, 346. — Ova- 
rian Hydrocele, 346. 

CHAPTER XXIX. 
Cystic Tumors of the Ovary 349 

Oophoritic Cysts, 350. — Follicular Cysts, 350. — Glandular Cysts, 
354. — Dermoid Cysts, 359. — Teratoma, 361. — Paroophoritic Cysts, or 
Papillomatous Ovarian Cysts, 362. 

CHAPTER XXX. 
Cysts of the Parovarium 368 

Comparison of Oophoritic, Paroophoritic, and Pai'ovarian Cysts, 372. 
— Glandular Oophoritic Cyst, 372. — Paroophoritic Cyst, 373. — Cysts 
of the Parovarium, 373. 

CHAPTER XXXI. 
Naturae History and Treatment of Ovarian Cysts . 374 

Secondary Changes or Accidents of Ovarian Cysts, 374. — Inflam- 
mation and Suppuration, 374. — Torsion of the Pedicle, or Axial Ro- 
tation, 375. — Rupture of Ovarian Cysts, 377. — The Clinical History 
of Ovarian Cysts, 378. — Examination, 383. — Treatment of Ovarian 

Cysts, 387. 

CHAPTER XXXII. 
Soeid Tumors of the Ovary 390 

Fibromata, 390. — Myomata, 390. — Sarcomata, 391. — Carcinomata, 
392. — Ovarian Papillomata, 393. — Tuberculosis of the Ovary, 393. — 
Tumors of the Ovarian Ligament, 394. 

CHAPTER XXXIII. 
Malformations of the Genitae Organs 395 

Uterus Unicornis, 396. — Uterus Didelphys, 396. — Uterus Bicornis 
Duplex, 396. — Uterus Bicornis Unicollis, 397. — Uterus Cordiformis, 
397. — Uterus Septus, 397. — Malformation of the Vagina, 397. — Her- 
maphroditism, 399. 

CHAPTER XXXIV. 
Disorders of Menstruation 402 

Amenorrhea, 405. — Acute Suppression of Menstruation, 407. — 
Scanty Menstruation, 407. — Vicarious Menstruation, 408. 



CONTENTS. . 13 

CHAPTER XXXV. 

PAGE 

The Menopause 409 

CHAPTER XXXVI. 
Genital Fistula 412 

Vesico-vaginal Fistula, 412. — Urethro- vaginal Fistula, 420. — Vesico- 
uterine Fistula, 420. — Uretero-vaginal Fistula, 421. — Recto- vaginal 
Fistula, 421. 

CHAPTER XXXVII. 
Diseases op the Urethra and Bladder 423 

Diseases of the Urethra, 426. — Urethritis, 427. — Stricture of the 
Urethra, 430. — Prolapse of the Mucous Membrane of the Urethra, 
431. — Vesico-urethral Fissure, 431. — Dilatation of Urethra, 433. — 
Urethrocele, 434. — Urethral Neoplasms, 434. — Urethral Caruncle, 
434. — Urethral Cysts, 435. — Polypus, 435. — Sarcoma and Cancer of 
the Urethra, 436. — Diseases of the Bladder, 436. — Cystitis, 437. — 
Vesical Calculus, 447. 

CHAPTER XXXVIII. 
Gonorrhea in Women 448 

CHAPTER XXXIX. 
The Technique of Gynecological Operations 457 

Operating-room, 461. — Apparatus, 462. — Operator, Assistants, 
Nurses, 463. — Sterilization of Dressings, Towels, etc., 466. — Sterili- 
zation of Instruments, 466. — The Water, 467. — Sponges, 468. — 
Discipline of the Operating-room, 469. — Anesthesia, 470. — Prepara- 
tion of the Patient, 471. — Instruments, 475. — The Dressing, 479. 

CHAPTER XL. 

The Technique of Gynecological Operations {Co?i- 
tinued) 4S0 

Abdominal Drainage, 480. — Gauze-drainage, 4S2. — Indications for 
Drainage, 484. — Vaginal Drainage, 487. — The Incision of the Ab- 
dominal Wall, 487. — Exploration of the Abdomen, 489. — Protection 
of the Intestines and Omentum, 489. — Toilet of the Peritoneum, 490. 
— Closing the Abdominal Incision, 491. 

CHAPTER XU. 
Treatment after Celiotomy 404 



1 4 CONTENTS. 

CHAPTER XLH. 

The Special Technique of Operations upon the Uterus 
and the Uterine Appendages 502 

Removal of the Uterine Appendages (Salpingo-oophorectomy), 504. 
— Removal of an Ovarian Cyst, 512. — Operation for the Removal of 
Intraligamentous Cysts, 5 1 4. — Marsupialization of the Cyst, 516. — 
Operation for Removal of the Uterus, 517. — Supra-vaginal Amputa- 
tion of the Uterus, 518. — Preservation of the Ovaries in Hysterec- 
tomy, 523. — Complete Abdominal Hysterectomy, 523 — Vaginal 
Hysterectomy, 527. — Combined Vaginal and Abdominal Hysterec- 
tomy, 531. — Abdominal Myomectomy, 533. 

CHAPTER XLIII. 
The Effect of the Removal of the Uterine Appen- 
dages 535 



krc>EX • ■" 537 



A TEXT-BOOK 

OF 

DISEASES OF WOMEN 



CHAPTER I. 
THE GENERAL CAUSES OF DISEASES OF WOMEN, 

Gynecology is the study of diseases peculiar to 
women. As woman possesses organs which man has 
not, and as the parts — physiological and social — that 
she plays in life differ from those played by man, we 
should expect to find her afnicted with a certain num- 
ber of diseases, peculiar to her, which are dependent 
upon her anatomy, physiology, and mode of life. Such 
diseases occur in barbarous as well as in civilized 
women; and similar diseases, peculiar to the female, 
occur in the lower animals. Thus, in the cow and the 
mare we find tumors of the vagina, prolapse of the vagina 
and uterus, fibroid tumors, sarcoma and cancer of the 
uterus, and some forms of ovarian cysts. Cysts of the 
tubes and the ovaries are exceedingly common in old 
mares; cats and goats are similarly affected. 

From a pathological point of view, however, the civil- 
ized woman unfortunately differs from her barbarous 
sister, and from the female of the lower animals, in many 
important particulars. She is more liable to the patho- 
logical conditions which, more or less, all females have 
in common. These conditions appear in a more severe 
form, and are followed by more disastrous results, in 
the civilized than in the barbarous state. 

The female among the lower animals and among 

15 



16 A TEXT-BOOK OF DISEASES OF WOMEN. 

savages seems to be about equal in proportionate 
strength and physical endurance to the male, though 
in size and in gross muscular strength she may be his 
inferior. Her subordinate position is often due not so 
much to any difference in strength as to the fact that 
the male possesses weapons — as the horns of the deer 
— with which nature has not endowed the female; and 
though she is liable to more diseases than the male, 
yet her relative position does not seem to be materially 
altered by this fact. The bitch is as enduring as the 
dog. The female grizzly is as ferocious and as danger- 
ous as the male. The mare is as fast as the horse. 
The squaw among the American Indians can lift and 
carry burdens which the lazy buck would not attempt. 

How different it is with the civilized woman, as we 
know her in this country ! The average healthy woman 
in this country is very much inferior in physical strength 
and endurance to the average man, and this inferiority 
is tremendously increased when she becomes sick from 
any of the diseases to which her sex is liable. 

The increased liability of the civilized woman to dis- 
ease is in a large measure due to her poor physique. 
But this is not all. 

The causes of many of the diseases with which the 
gynecologist has to deal cannot be traced so easily. 

Fibroid tumors of the uterus, which are so common 
among the colored women of this country, are said by 
Tait to be unknown among their African cousins, who 
are removed by but a few generations. 

The most common causes of diseases of women are 
injuries received during parturition; sepsis; venereal dis- 
eases; errors of development; improper mode of life and 
clothing during the period of development; neglect dur- 
ing menstruation; and celibacy. 

The results of the injuries received during parturition 
are most numerous. They may appear immediately, a 
short time after labor, or at some remote period. The 
disabilities attending laceration through the sphincter 



GENERAL CAUSES OF DISEASES OF WOMEN. 77 

ani or a recto-vaginal or vesico-vaginal fistula appear 
before the mother leaves her bed. The suffering from 
a laceration of the cervix, a subinvolution of the uterus, 
or a retrodisplacement may not be felt for some weeks 
or months after labor; while the still more remote re- 
sult, the development of cancer, may not appear for 
many years, though it can be positively traced to the 
lesion in the cervix as the primary cause. 

Septic infection of the genital tract kills or makes 
invalids of many women. The infection occurs at the 
time of a miscarriage or of a normal labor, or it may be 
acquired from the dirty instruments or the dirty hands 
of a physician. It is not a cause of disease among civil- 
ized women alone, but occurs among barbarous and 
semi-barbarous races. 

Venereal disease, especially gonorrhea, has been said 
to be the most common cause of disease among women. 
The disease extends from the external genitals through 
the uterus and Fallopian tubes, causing sterility, chronic 
invalidism, and death from peritonitis. 

Errors of development are frequent causes of disease 
and suffering among women. Atresia of the vagina or 
of the cervix uteri, by causing retention of the uterine 
discharges, produces most serious pathological conditions. 
Arrested development of the whole or of part of the 
uterus is a common cause of disease. 

Improper clothing and an improper mode of life dur- 
ing the period of development are most fertile sources of 
diseases of women. Clothing which contracts the waist, 
as well as clothing which, though not unduly tight in 
the inactive state, yet interferes with abdominal respira- 
tion during activity, is most injurious. Such clothing 
diminishes the capacity of inspiration by restricting ab- 
dominal expansion, and thus crowds down the pelvic 
organs toward the pelvic floor; and the continuous sup- 
port to the abdominal walls diminishes their natural 
muscular strength and places the woman in a condition 
predisposing to the various displacements oi the uterus. 
2 



18 A TEXT-BOOK OF DISEASES OF WOMEN. 

An improper mode of life, irregular hours for sleeping 
and eating, insufficient exercise, and lack of fresh air and 
sun, resulting in poor muscular development, seem to 
predispose the woman, as the man, to a variety of patho- 
logical conditions; but as the reproductive apparatus in 
woman is more delicately organized, and as, during the 
period of active life, this is really her chief part, it more 
especially suffers as a result of any general systemic 
derangement. 

Neglect during menstruation, especially in the young 
girl, is a frequent cause of subsequent suffering. The 
effect of menstruation upon the whole system is remark- 
able. The nervous, vascular, and digestive systems all 
share in the menstrual function. The usual work of the 
girl at school or other employment should be altered to 
suit the altered conditions of her body at the menstrual 
period. I^ong school hours and close mental application 
or active exercise are too often continued at this time. 

Celibacy is an unnatural state and a common cause of 
disease. Certain forms of fibroid tumors of the uterus 
are more common in single than in married women, and 
more common in sterile than in childbearing women. 
And the painful cirrhotic ovaries of the old maid are the 
result of the unceasing menstrual congestions never 
relieved by pregnancy and lactation. 



CHAPTER II. 
METHODS OF EXAMINATION. 

In order to make a complete gynecological examina- 
tion, we must examine the abdomen, the external organs 
of generation, and the pelvic structures. 

Examination of the Abdomen. — In order to make 
a perfectly satisfactory examination of the abdomen, the 
woman should be in bed, with all clothing removed ex- 
cept the undershirt and the night-dress, which should be 
drawn well up above the costal margin. Examination 
made with any constricting clothing about the waist or 
about the lower thorax is most unsatisfactory. 

The abdomen is examined by inspection, palpation, 
percussion, and auscultation. 

The woman should lie flat upon her back, and the 
abdomen should be thoroughly exposed. We can then 
determine by inspection the presence of dilated veins or 
of linese albican tes, the general size and form of the 
abdomen, the occurrence of any abdominal movement, 
and the presence of any asymmetry in the abdominal 
contour, such as would be made by the bulge of a tumor 
or the displacement of an abdominal organ. The shape 
of the abdomen, even though symmetrical, is often diag- 
nostic of certain intra-abdominal conditions. Thus, an 
abdominal enlargement that is due merely to fat presents 
a different contour from the enlargement caused bv -tvm- 
panitic distention of the intestine. The enlargement due 
to ascites, or free fluid in the peritoneum, differs in con- 
tour from that caused by an encysted collection of fluid. 

It should, be remembered that linese albicantes arc not 
always the result of pregnancy, but that they may have 

19 



20 A TEXT-BOOK OF DISEASES OF WOMEN. 

been caused by distention of the abdomen from some 
other cause. 

Palpation. — We can determine most by palpation of 
the abdomen. The examiner should always remember 
that it is most important to secure the patient's con- 
fidence, and to proceed so gently, slowly, and gradually 
in performing palpation that no voluntary or reflex con- 
traction of the abdominal muscles may impede his ma- 
nipulations. 

In cases in which there is a sore or tender spot within 
the abdomen the contraction of the recti muscles may be 
altogether involuntary, persisting even when the patient 
is anesthetized. We see this in the rigid right rectus 
muscle of appendicitis. The hands should be warmed, 
and palpation should be performed with both hands. A 
certain amount of gentle stroking or massage of the 
abdomen will secure the patient's confidence by making 
her feel that she will not be hurt by any sudden violent 
pressure, and will also prevent reflex contraction of the 
muscles. By proceeding in this way, slowly, the exam- 
iner can palpate the whole of the abdominal surface, 
exploring first the structures lying most anterior, and 
then, pressing the fingers more deeply, he can examine 
the more posterior structures. 

Fluctuation in an encysted fluid accumulation is sen- 
erally readily determined. While one hand is placed 
against one side of the fluid mass and the opposite side 
is percussed by the fingers of the other hand, the wave 
of fluctuation is easily felt. Sometimes a thrill or a false 
wave of fluctuation is observed in the subcutaneous fat 
of obese women. This disturbing element may, how- 
ever, be eliminated by an assistant pressing the ulnar 
edge of his hand in the median line upon the abdominal 
surface, thus stopping the fat wave of fluctuation. 

Special organs in the abdomen sometimes require 
special methods of examination. It is very often neces- 
sary for the gynecologist to examine the kidneys, because 
many women have movable or floating kidneys, and the 



ME THODS OF EXAMINA TION. 2 1 

nervous, gastric, and abdominal symptoms may be due 
to this condition. The presence of a floating kidney 
may often be determined by inspection; the presence of a 
movable kidney, however, must be determined by palpa- 
tion. This should be performed with the woman in the 
sitting, or standing, erect posture; or sitting upon the 
edge of a chair, with the body inclined somewhat for- 
ward and the hands upon the knees; or lying upon a bed, 
on the side opposite the kidney that is being examined. 
One hand should be placed over the lumbar muscles; the 
other hand should be placed upon the anterior abdominal 
wall immediately below the costal margin, and should 
be pressed backward. If the kidney lies below its nor- 
mal position, it may in this way be brought between the 
two hands, and can be felt to glide upward as the hands 
are pressed together. In case a movable kidney cannot 
readily be found, because it may have returned to its 
normal position, it may often be brought down again if 
the woman is made to cough. 

In a thin woman the vermiform appendix may some- 
times be felt through the abdominal wall; and in cases 
of pain and inflammation in the right iliac region it is 
sometimes important to determine whether or not the 
trouble has started in the vermiform appendix or in the 
Fallopian tube. In order to palpate the vermiform ap- 
pendix the examiner should stand upon the right side 
of the woman, who is lying upon her back, and should 
place the tips of the fingers of the right hand at about 
the junction of the upper and middle thirds of a line 
drawn from the middle of Poupart's ligament to the um- 
bilicus. By pressing backward firmly and gently, pul- 
sations of the right common iliac artery may be felt ; 
and then by drawing the hand directly outward it will 
pass over the different structures in this region lying 
between the palpating hand and the posterior abdom- 
inal wall. The appendix may often be felt, especially 
if it is indurated by inflammation. 

Percussion of the abdomen should be performed with 



22 A TEXT-BOOK OF DISEASES OF WOMEN. 

the woman in the dorsal position; though, if the exam- 
iner suspects the presence of free fluid in the peritoneum, 
or ascites, much may be learned by percussing in differ- 
ent positions and noting the accompanying changes in 
the percussion-note. 

Percussion should then be performed with the woman 
upon her back, upon the right side, upon the left side, 
sitting up, and upon the hands and knees. An encysted 
fluid accumulation will give practically the same result 
in percussion in all positions, while free fluid will gravi- 
tate to the most dependent portion. 

Auscultation of the abdomen is best performed with 
the stethoscope. By it we may hear fetal heart-sounds, 
uterine souffle, placental bruit, peritoneal friction sounds, 
and the peristaltic sounds of the intestinal tract. All 
of these sounds are of importance, and the presence or 
absence of any of them may have an important bearing 
upon the diagnosis of the case. 

Examination of External Genitals and Pelvic 
Structures. — To examine the external organs of genera- 
tion and the pelvic viscera the woman should be placed 
upon a table. In some cases the physician may be 
obliged, for want of proper facilities or on account of 
the physical condition of the patient, to make his ex- 
amination upon a bed. Such an examination, however, 
is never so satisfactory or so thorough as the examina- 
tion made with the woman upon the examining-table. 
A great number of gynecological tables have been intro- 
duced. The one which seems to the writer the best, on 
account of its simplicity and the perfect relaxation of 
the abdominal muscles furnished by it, is shown in the 
accompanying illustration (Fig. i). It is a plain wooden 
table, at the foot of which are attached the upright sup- 
ports for holding the stirrups for the feet, such as have 
been devised by Dr. Edebohls. By this arrangement the 
feet and legs are supported without any effort on the part 
of the woman; when the buttocks are drawn well down 
to the foot of the table there is a certain amount of flexion 



METHODS OF EXAMINA TION. 



23 



of the pelvis upon the trunk, and the most complete 
attainable relaxation of the abdominal muscles is secured. 

When the woman has been placed in this position the 
examiner should investigate thoroughly, and in order, the 
following structures: The anus, the perineum, the labia 
majora, the nymphse, the 
fourchette, the orifices of 
the ducts of the vulvo- 
vaginal glands, the hymen 
or its remains, the vestibule 
and the small glands of the 
vestibule, the external uri- 
nary meatus, and the clit- 
oris. 

To determine any patho- 
logical condition of these 
structures it is necessary 
that the physician should 
be familiar with the appear- 
ance in the normal woman, 
and to gain such essential 
knowledge we should avail 
ourselves of every opportu- 
nity offered to make a criti- 
cal examination of the external genitals of women, going 
over all the different structures in order. 

Vaginal and Bimanual Examination. — Having ex- 
amined and noted the condition of the external genitals, 
the physician should next proceed to examine the va- 
gina. The index finger of the right or the left hand 
should be gently introduced into the vagina. The con- 
dition of the vaginal walls, and the direction, consist- 
ency, form, etc. of the vaginal cervix, may be deter- 
mined. The shape and size of the os uteri should be noted. 
The ulnar edge and the tips of the fingers of the other 
hand should then be placed upon the abdomen, immedi- 
ately above the symphysis pubis, and gently pressed 
backward and downward toward the vaginal finger 




Fig. 1. — Woman in the dorsal po- 
sition with feet supported in Edebohls' 
stirrups. 



24 A TEXT-BOOK OF DISEASES OF WOMEN. 

(Fig. 2). In this way the various pelvic organs, the 
uterus, Fallopian tubes, ovaries, and ureters, may be 
palpated between the two hands, and their position, 




Fig. 2. — Bimanual examination. 



size, shape, and consistency may be determined. Such 
an examination is, of course, made much more easily 
in a thin woman than in a fat one. A thin woman a 
few weeks after labor may be examined most easily, on 
account of the relaxation of the abdominal and vaginal 
walls. 

This is called the bimanual method of examination, 
and the student will find that as he acquires practice in 
this method he will gradually depend less upon examina- 
tion by the uterine sound and the speculum, and will 
rely altogether upon his sense of touch, his ability to 
palpate. 

It matters not which hand be used in making the vag- 
inal examination. It will, however, be found that the 
hand that is used the more frequently will become the 
more proficient. 

In making the bimanual examination the structures 



METHODS OF EXAM IN A TION. 



25 



should be palpated methodically in order. The vaginal 
ringer notes the condition of the cervix uteri. If the 
fundus be in the normal position, the uterus can then be 
taken between the abdominal hand (upon the fundus) and 
the vaginal finger (upon the cervix) (Fig. 3). The shape, 




Fig. 3. — Bimanual examination ; median sagittal section of the pelvis. 



size, mobility, and consistency are noted. The vaginal 
finger is then passed anteriorly and laterally toward either 
uterine cornu, while the abdominal fingers pass over to 
the posterior aspect of the same cornu. The ovarian 
ligament and the proximal end of the Fallopian tube 
may thus be felt. Passing farther outward, the whole of 
the tube and the ovary may be examined. The same 
procedure is then applied to the opposite side. 

The condition of the ureters may be determined by 
placing the vaginal finger in either lateral vaginal fornix 
and drawing it outward and forward, when these struc- 
tures will pass over the end of the finger. When the 



26 A TEXT-BOOK OF DISEASES OF WOMEN. 

ureters are indurated by inflammation they can be plainly 
felt. 

By the method of examination here advised the physi- 
cian will always make a visual examination before mak- 
ing a digital one. There are several advantages derived 
from this procedure. In the first place, no examination 
of a woman is thorough unless a careful visual examina- 
tion of the external genitals has been made. The discov- 
ery of discharges and of lesions of the external genitals 
may throw much light upon the condition found higher up 
in the pelvis. Again, the examiner protects himself. A 
great many unfortunate cases of syphilis have been ac- 
quired by physicians from a primary sore upon the exam- 
ining finger. A preliminary visual examination enables 
one to guard against this danger. The primary sore 
occurs upon the end of the examining finger or upon the 
web between the index and middle fingers — the part of 
the hand that is pressed against the fourchette. 

The hands of the physician should, of course, be surgi- 
cally clean before making an examination, and the grease 
or oil which is used as a lubricant should be clean. The 
hands should always be washed, after separating the parts 
to make the visual examination, before the finger is thrust 
into the vessel containing the lubricant. It is best to 
place a small portion of the lubricant on a plate or a 
saucer for each individual patient, and thus avoid the 
danger of contaminating the rest. Carbolized oil, borated 
vaseline or cosmoline, and a thick sterile solution of soap 
are good lubricants. Neutral green soap diluted with 
boiled water to the consistency of thin jelly is a very 
agreeable lubricant which may easily be washed from the 
hands and the vagina. 

If practicable, the woman should receive a vaginal 
douche of bichloride-of-mercury solution, i : 4000, and 
the vulva should be washed, before making a biman- 
ual examination. The examiner should always clean the 
external genitals of all discharges before introducing the 
vaginal finger. In this way we avoid the danger of 



ME THODS OF EXAM IN A TION. 2 J 

carrying septic material from the external genitals to the 
upper portion of the genital tract. This preliminary 
cleansing is not desirable before the external genitals 
have been examined; for much may be learned from 
observation of the discharges which bathe or escape from 
the various structures. If practicable, a cleansing vaginal 
douche of bichloride-of-mercury solution should be admin- 
istered after the bimanual examination. 

The examination of the uterus and other pelvic struc- 
tures is often facilitated by dragging the uterus downward 
with a tenaculum while the vaginal or the bimanual 
examination is being made. Sensation in the cervix is 
so slight that little or no pain is experienced in this pro- 
cedure. The anterior or posterior lip of the cervix is 
caught with the single or the double tenaculum (Fig. 4), 



Fig. 4. — Double tenaculum. 

guided along the vaginal finger or introduced through 
the speculum, and the uterus is drawn down by an assist- 
ant in case the bimanual examination is being made, or 
by the external hand of the examiner in case a simple vag- 
inal examination is made. When this is done the utero- 
sacral ligaments are made tense, and can be felt like two 
cords extending from the sides of the cervix outward and 
backward to the pelvic wall. The posterior surface of 
the uterus can be palpated often as high up as the fundus. 
The method is especially useful when the examination is 
made by the rectum, and in this way the whole posterior 
surface and the fundus of the uterus may be palpated 

(Fig- 5)- 

The contraindications to a vaginal examination are 



28 A TEXT-BOOK OF DISEASES OF WOMEN. 

virginity, the presence of a hymen, and any acute in- 
flammatory or painful condition of the vulva or vagina. 
None of these conditions, however, forbid an examina- 
tion if an exact diagnosis is essential to the proper treat- 
ment of the case, and can be made only in this way. It 




FlG. 5. — Bimanual examination with one linger in the rectum, 
drawn down with the double tenaculum. 



The uterus is 



may be that in these cases a rectal examination will be 
sufficient for diagnosis. 

Rectal examination of the pelvic structures is made in 
a way similar to that already described for the vaginal 
examination. Bimanual examination may be made by 
palpating the various organs between the rectal finger 
and the abdominal hand. 

The Vaginal Speculum. — The speculum is an instru- 
ment through which a visual examination is made of the 
vagina, the external os uteri, and the vaginal cervix. A 



METHODS OF EXAMINA TION. 



2 9 



great number of specula have been invented. At the 
present day the best two instruments of this class are 
the bivalve speculum, such as Goodell's (Fig. 6), and 




Fig. 6. — Goodell's speculum. 



the duck-bill speculum (Fig. 7), or perineal retractor, 
invented by Sims. 




Fig. 7. — Sims' speculum. 

The bivalve speculum is introduced with the woman 
upon her back, in the dorso-sacral position already de- 




Fig. 8. — Sims' depressor for the anterior vaginal wall. 

scribed. The vulva and the vagina should be cleaned. 
The speculum should be warmed by placing it in hot 
water, and should then be lubricated with the soap solu- 
tion or with vaseline. It should be introduced with the 
blades closed and the plane of the blades lying not ex- 



3° 



A TEXT-BOOK OF DISEASES OF WOMEN. 



actly in the median sagittal plane of the body, but in- 
clined at a small acute angle to this plane, one edge of the 
speculum being directed toward either vaginal sulcus. 
The instrument is passed into the vagina toward the posi- 
tion in which, by a previous digital examination, the vag- 
inal cervix had been found to lie. The instrument is then 
turned with the handles toward either thigh, so that the 
blades become parallel to the anterior and posterior vag- 
inal walls, in order that, when separated, they will open 
the vaginal slit. The handles are brought together and 




Fig. 9. — Goodell's speculum in position. 

the blades opened. When the vaginal cervix comes 
well into view the blades are fixed in place by the screws 
(Fig. 9). 

In some cases, where the cervix points well forward 
or well backward, it may be readily brought into view 
through the speculum by catching it with a tenaculum. 

By means of the bivalve speculum we are able to make 
a partial inspection of the vaginal walls, an imperfect 
inspection of the vaginal vault, and a good inspection 
of the vaginal cervix and the external os. Applications 



METHODS OF EX AM IN A TION. 



31 



can be made to the cervix, but none of the minor ope- 
rations of gynecology can be performed through this 
speculum. 

The Sims speculum enables us to make the most thor- 
ough inspection of the vagina, the vaginal vault, and the 
vaginal cervix. The Sims speculum is merely a hook or 
retractor for the perineum, and may be introduced with 
the woman in the dorsal position, the Sims position, or 
the genu-pectoral position. If the Sims speculum is 
introduced in the dorso-sacral position, it is necessary 




Fig. 10. — The Sims position. 



to hold forward the anterior vaginal wall in order to 
obtain a view of the cervix. 

The Sims position, which is also called the latero- 
abdominal position, is shown in Fig. 10. The woman 
is placed on the bed or table upon her left side. The 
side of the face is upon the pillow; the left arm is behind 
the back, so that the left breast rests upon the table. 
The thighs are flexed upon the abdomen at an angle of 
about 90 to the trunk. The right thigh is more flexed 
than the left, so that the right knee may touch the table 
above the left knee. The legs are flexed on the thighs. 
In this position there is a tendency for the intestines, 
following the force of gravity, to fall from the pelvis, 



32 



A TEXT-BOOK OF DISEASES OF WOMEN. 



and for the uterus and other pelvic viscera to be drawn 
up. When the perineum is retracted with the blade of 
the Sims speculum, air will enter the vagina and the 
vaginal slit will become distended (Fig. n). To facili- 




Fig. II. — The cervix uteri exposed with the Sims speculum. 

tate inspection of the cervix it is usually necessary also 
to push forward the anterior abdominal wall by some 
kind of depressor, such as the one shown in Fig. 8. 




Fig. 12. — The knee-chest position 



The genu-pectoral position or the knee-chest position is 
shown in Fig. 12. The side of the face is upon the pillow; 
the breast is upon the table; the thighs are vertical. In 



METHODS OF EXAMINA TION. 



33 



this position the intestines fall from the pelvis, and the 
other pelvic viscera are drawn upward by the force of 
gravity. If the anus is opened, air rushes in and dis- 
tends the rectum. If the perineum is retracted, air 
enters and distends the vagina. If the urethra is opened, 
the bladder is likewise distended. The position is the 
most useful one for inspection of the rectum, vagina and 
vaginal cervix, and the bladder. 

The Sims speculum, with the woman in the dorsal, the 
Sims, or the knee-chest position, is the most useful in- 
strument by which to expose the cervix uteri for any of 
the minor operations of gynecology. The manipulations 
of the operator are not hampered by working between 
metal walls. 

Examination of the Rectum.— If the woman is 
placed in the knee-chest position, a most satisfactory 
inspection of the whole of the rectum may be made. 
The woman should be placed in this position with the 
buttocks before a good light, and the posterior margin 
of the anus should be retracted by the small blade of a 




Fig. 13. — Rectal speculum, large size. Fig. 14. — Rectal speculum, small size. 

Sims speculum; the rectum will immediately become 
distended with air and the rectal walls will be well ex- 
posed. Or the rectal specula (Figs. 13, 14) may be used. 
In employing the longer of these instruments it is best 
to use light reflected from a head-mirror or thrown 
directly from an electric head-light into the speculum. 
The instrument should always be introduced for the 
3 



34 



A TEXT-BOOK OF DISEASES OF WOMEN. 




first two inches with the obturator in place. The obtu- 
rator should then be withdrawn and the speculum pushed 
farther in, the operator watching and guiding its course 
around the rectal valves or folds of mucous membrane, 
so as to prevent injury to the walls of 
the rectum. Anesthesia is not neces- 
sary for this procedure. 
Examination of the Bladder. — It 
will readily be understood that all the hol- 
low viscera are much more easily examined 
when their walls are separated by distention 
with air than when the walls are collapsed. 
The bladder is most readily examined in 
this way. The woman should be placed 
in the knee-chest position, or in the dorsal 
position with the hips elevated above the 
abdomen. In either position the intestines 
fall from the pelvis, and when the urethra 
is opened air enters and distends the blad- 
der. This distention is most certainly ac- 
complished in the knee-chest position. In 
women who are not very fat, however, the 
extreme dorso-sacral position is equally good. 
The details of this method of examination 
are described on a later page. 

The uterine sound is an instrument by 

which the length of the uterine cavity may 

be determined (Fig. 15). The sound, which 

is a large surgical probe, somewhat curved 

to adapt itself to the normal shape of the 

uterine axis, is made of pliable metal, so 

that the curvature may be changed readily 

to suit any case. The sound is graduated, 

and at a position of 2j4 inches from the tip is a small 

elevation marking the length of the normal uterine 

cavity. 

The uterine sound was at one time used a great deal to 
determine the length and direction of the uterus, and 



Fig. 15. — Ute- 
rine sound. 



ME THODS OF EXAMINA TION. 35 

perhaps to assist in determining the character of the 
uterine contents or of the endometrium. With our 
present methods of examination, however, the sound is 
of but little if any use. The size and direction of the 
uterus can in nearly all cases be determined by bimanual 
examination. The use of the uterine sound is by no 
means free from danger. Many cases of septic endo- 
metritis and salpingitis have been caused by it, and the 
physician has often unintentionally committed an abor- 
tion by passing the sound in a pregnant woman. The 
uterine sound should never be used in a routine way. It 
should never be used unless one expects to determine 
with it something that cannot be determined by simpler 
methods of examination. 

The most thorough aseptic precautions should be ob- 
served when the sound is introduced. The vulva, vagina, 
and cervix should be cleaned and the sound should be 
sterilized. The sound should never be introduced if 
there is any suspicion of pregnancy. 

Antisepsis. — In all examinations the physician should 
observe every precaution to avoid carrying infection from 
one patient to another. All instruments used in the ex- 
amination should be thoroughly cleansed with soap and 
warm water, and then boiled for five minutes in a i-per 
cent, solution of carbonate of soda. 



CHAPTER III. 
DISEASES OF THE EXTERNAL GENITALS. 

Vulvitis. — Vulvitis, or inflammation of the vulva, is 
not a common disease. The vulva is composed of several 
parts which are anatomically distinct, and, though all 
these parts are usually involved in an acute attack of 
inflammation of the vulva, yet the symptoms of the dis- 
ease and the pathological appearance depend to a great 
extent upon the structures which are principally affected. 
The labia majora, the nymphse, the vestibule with its 
mucous crypts or glands, the clitoris, the external uri- 
nary meatus, and the ducts of Bartholin's glands may all 
be involved in the inflammation. The sebaceous glands 
of the labia may be especially involved, producing a form 
of sebaceous acne which has been called follicular vul- 
vitis. Inguinal adenitis may accompany vulvitis. 

The appearance of the parts is that characteristic of in- 
flammation of the skin and mucous membrane in any 
other part of the body. The mucous membrane becomes 
red and swollen; the labia may become edematous; an 
abundant purulent discharge covers the parts, and unless 
cleanliness is practised the irritation from the discharge 
spreads to the inner aspects of the thighs, the perineum, 
and the anal region. 

The patient suffers with local pain, which is increased 
by walking and by the passage or contact of urine. 

The usual cause of vulvitis is gonorrhea. The con- 
dition is sometimes secondary to other diseases. It may 
be caused by the irritation from the discharges of a 
vesico-vaginal or recto-vaginal fistula, from a cancer of 
the cervix or in some forms of endometritis. Girls and 

36 



DISEASES OF THE EXTERNAL GENITALS. tf 

women who are unclean may be attacked by vulvitis as a 
result of irritation from decomposed smegma, sweat, 
urine, etc. The oxyuris, or thread- worm, may enter the 
vulva from the rectum and cause, in unclean children, 
sufficient irritation to produce inflammation. Vulvitis 
from uncleanliness is most likely to occur in hot weather 
after prolonged exercise. It not infrequently attacks 
children, especially those of a strumous diathesis, whose 
hygienic surroundings are poor. In such cases the sus- 
picions of the parents may demand a medico-legal exam- 
ination; and it is of importance to remember that vul- 
vitis of this kind is not rare, and is not due to violation 
or contagion. Vulvitis in little girls may be also due to 
gonorrhea, independently of violation. This is the cause 
of epidemics of vulvitis and vaginitis in girls crowded in 
houses, hospitals, or asylums. The disease is spread by 
contamination from towels or bed-clothing. 

The essential points of treatment to observe in the 
acute stage of vulvitis are rest in the recumbent posture 
and perfect cleanliness. The labia should be separated 
and the parts frequently bathed and cleaned with warm 
water. Various local washes or applications are of use. 
A warm solution of boracic acid (3J to a pint of water), 
the dilute solution of the subacetate of lead, or a solution 
of bichloride of mercury (i : 5000) may be used. 

If the disease is of gonorrheal origin, the parts should 
be painted once or twice a day with a 2 per cent, solution 
of nitrate of silver, applied after the discharges have 
been gently washed away. 

As the disease subsides the inflammation may be found 
to persist in the crypts of the vestibule, the urinary 
meatus, and the ducts of Bartholin's glands. It is very 
important that all remains of the inflammation, especially 
if it be of septic or gonorrheal origin, should be eradi- 
cated before the woman is discharged from treatment. 
The presence of any focus of inflammation, even though 
latent, is a constant source of danger to the woman; for sep- 
tic organisms or material may be carried from the external 



38 



A TEXT-BOOK OF DISEASES OF WOMEN. 



genitals to the higher parts of the genital tract, as the uterus 
and Fallopian tubes, with the most disastrous results. 

Sometimes a small drop of pus will be observed escap- 
ing from one of the small glands or crypts of the vesti- 
bule, about the urinary meatus, after the inflammation 
has disappeared in other parts of the vulva. In this case 
the gland should be punctured with a fine cautery-point 
or a fine wooden probe or point saturated with pure car- 
bolic acid or other caustic. 

If the disease persists in the external meatus or urethra, 
it must be treated by the local applications appropriate 
for urethritis. 

Inflammation of the Vulvo- vaginal Glands. — The 
vulvo-vaginal glands are two in number. They are 



G.m. 




Fig. 16. — Appearance of the external genitals in a woman with gonorrhea: 
G. ?)i., gonorrheal macula situated at the base of a vaginal caruncle. 

about the size of a bean, and are situated deeply on the 
inner aspect of the labia majora, where they may be 
felt in thin women. The duct of the gland is about one 






DISEASES OF THE EXTERNAL GENITALS. 39 

inch in length, and opens immediately in front of the 
hymen, about the middle of the side of the ostium 
vaginae. In cases of vulvitis the duct of the gland 
usually becomes inflamed, and the inflammation may 
extend to the gland, producing abscess of the vulvovag- 
inal gland. 

Inflammation of the duct and the gland may also occur 
independently of vulvitis, from direct septic or gonorrheal 
infection. 

Suppuration of the duct may be demonstrated by press- 
ing over the course of the duct, when a drop of pus will 
escape from the opening. In such cases the orifice of 
the duct is usually surrounded by a red areola, resembling 
a flea-bite, which has been called the gonorrheal macula 
(Fig. 16). This macula persists long after all other traces 
of inflammation about the vulva and vagina have dis- 
appeared, and after all frank suppuration in the duct has 
subsided. Its presence indicates at least the probability 
of previous gonorrheal infection. 

When the duct of the gland alone is the seat of inflam- 
mation, it should be laid open with fine scissors or knife, 
and the tract thoroughly cauterized with the nitrate-of- 
silver stick, pure carbolic acid, or a solution of chloride 
of zinc (2 per cent.). 

Suppuration of the vulvo-vaginal gland is accom- 
panied by marked swelling and peripheral edema. The 
swelling may extend to the anus, and is of characteristic 
shape (Fig. 17). The pain is always severe. Fluctua- 
tion is first apparent on the inner surface of the labium 
majus. If the condition is not treated, one or more 
fistulous openings appear below the orifice of the duct, 
and the pus is discharged. The condition then becomes 
chronic. The fistulous openings persist. Acute inflam- 
mation disappears from the gland, leaving it in a con- 
dition of hypertrophic induration. A thin, milky or 
greenish, purulent fluid may be pressed out of the duct 
or the fistulous openings. Infection from this discharge 
may be communicated to man, or may ascend the genital 



40 A TEXT-BOOK OF DISEASES OF WOMEN. 

tract, producing inflammation of the endometrium or of 
the Fallopian tubes. 

In abscess of the vuivo-vaginal gland a free incision 
should immediately be made into the labium at the junc- 
tion of the skin and the mucous membrane. The interior 
should be wiped out with pure carbolic acid and the cav- 




Fig. 17. — Abscess of right vulvo- vaginal gland. 



ity packed with gauze. If the disease is first seen in the 
chronic stage, after the abscess has evacuated itself, the 
only method of cure is to excise, with curved scissors, 
the whole of the indurated gland, the duct, and the fis- 
tulous tracts. The wound may be left open and packed, 
or it may be closed immediately with buried catgut 
sutures. 
Cysts of the Vulvovaginal Glands. — Cysts may 



DISEASES OF THE EXTERNAL GENITALS. 41 

occur in the duct of the vulvo-vaginal gland or in the 
gland itself. Cysts of the duct are small — about the size 
of a chestnut. They are situated superficially, lying 
immediately under the mucous membrane of the vagina 
at the base of the labium minus. 







Fig. 18. — Cyst of the right vulvo-vaginal gland (Hirst). 

Cysts of the gland may be unilocular if formed at the 
expense of a single lobule of the gland, or multilocular 
if several lobules enter into their formation. These cysts 
may attain the size of the fetal head (Fig. 18). 

Cysts of the gland or of the duct are formed by reten- 
tion of the cyst-contents. The retention is due to occlu- 
sion of the duct, usually the result of inflammation. In 
some cases the duct remains pervious, and the retention 
is due to the altered character of the secretion ot the 
gland, which becomes too viscous to pass, except under 
unusual pressure, along the duct. 

These cysts contain clear yellow or chocolate-colored 



42 A TEXT-BOOK OF DISEASES OF WOMEN. 

fluid. The diagnosis of cyst of the vulvo-vaginal gland 
is usually not difficult. If we are in doubt in regard to 
the fluid character of the tumor, this may be determined 
with the exploring-needle. 

Inguinal hernia, hydrocele of the canal of Niick, cysts 
of the round ligament, and sacculated cysts of old her- 
nial sacs may be mistaken for cysts of the vulvo-vaginal 
glands. In such cases, however, the tumor lies more in 
the upper and outer part of the labium majus, and ex- 
tends to, and may be connected with, the external in- 
guinal ring. 

Cysts of the vulvo-vaginal glands should be treated by 
free incision and packing, or by extirpation. If the sac 
is emptied by the aspirator or by a small incision, it will 
refill. The best method is to extirpate the cyst. In case 
there has been no inflammatory action binding the cyst 
to surrounding structures, extirpation without rupture is 
easy. If rupture occurs, the cyst- wall may be dissected 
off with the knife or removed with the curved scissors. 
The wound may be immediately closed with deep and 
superficial sutures. 

Pruritus Vulvae. — Pruritus vulvae, or itching of the 
vulva, may be due to a great variety of causes. Erup- 
tions of the vulva, such as eczema, cause itching. Irri- 
tation from the discharge of vaginitis, metritis, cancer 
of the cervix or body of the uterus, the presence in chil- 
dren of the thread-worm, the irritation from diabetic 
urine, or trophic lesions of the nerves due to diabetes, 
may result in pruritus. Some of the pathological con- 
ditions of the uterus, tubes, and ovaries may produce 
reflex irritation of the nerves of the vulva, and cause 
itching, in a manner similar to that in which vesical cal- 
culus causes itching of the glans penis. 

The congestion of the external genitals that accom- 
panies pregnancy may also produce pruritus. 

There are some cases of pruritus vulvae, however, in 
which no physical cause for the intolerable itching can 
be discovered, and in which minute examination of the 
affected portions of skin or mucous membrane demon- 



DISEASES OF THE EXTERNAL GENITALS. 43 

strates no pathological change. Such cases are called 
idiopathic. 

The itching may be so severe that the woman cannot 
refrain from scratching and rubbing the parts on all oc- 
casions. She becomes debarred from the society of her 
friends, and seeks relief in anodynes and hypnotics. The 
continual scratching increases the irritation of the vulva, 
and an eczematous eruption may result, which produces 
an irritating discharge that spreads the irritation to other 
parts of the body with which it may come in contact. 

The itching of pruritus may extend into the vagina, to 
the skin of the abdomen, to the inner aspect of the thighs, 
and to the anus. 

In the treatment of pruritus it is first of importance to 
discover, if possible, the cause of the itching. Any 
vaginal or uterine discharge should be investigated. 
Discharge from the uterus can be eliminated as a cause 
by placing against the external os a pledget of cotton, 
frequently renewed, to absorb the discharge before it 
reaches the vulva, or the parts may be kept clean by 
frequent douches. In children the stools should be ex- 
amined for the thread-worm. The urine should always 
be examined. Diabetes is a frequent cause of pruritus 
vulvae in old women. Any pathological condition of the 
uterus, Fallopian tubes, and ovaries should be treated 
before we can eliminate this as a possible cause of pru- 
ritus. 

In the cases of so-called idiopathic pruritus in which 
no local lesion can be discovered attention should be 
directed to the general nutrition of the patient. As in 
pruritus ani, the gouty diathesis may cause the disease. 
Alcoholic drinks, rich food, fish and shell-fish, may assist 
in its production. 

Treatment. — A great variety of local applications have 
been used for the relief of pruritus. In case of diabetes 
the urine should, as much as possible, be kept from con- 
tact with the parts, which should be thoroughly dried 
after urinating, and dusted with a powder consisting 



44 A TEXT-BOOK OF DISEASES OF WOMEN. 

of equal parts of subnitrate of bismuth and prepared 
chalk. 

The following local applications are useful in pruritus: 

Bichloride of mercury, gr. y 2 ; 

Emulsion of bitter almonds, 3j, 

applied twice a day. 

A powder of i grain of morphine to 2 grains of pre- 
pared chalk, applied twice a day. 

Tfy. Tinct. opii, 
Tinct. iodi, 

Tinct. aconit, da. 3v; 

Acid, carbolic, 3J, 

applied once or twice in the twenty-four hours. 

An ethereal solution of iodoform sprayed into the folds 
of the vulva with an atomizer. 

Cauterization with pure carbolic acid. 

In pruritus of gouty origin an ointment, composed of 
15 grains of calomel to 1 dram of cerate, will often relieve 
or cure the local condition. A small quantity should be 
rubbed over the itching area at bed-time. Often one or 
two applications give immediate relief. If the condition 
does not quickly improve it is useless to continue this 
treatment. The danger of salivation from its prolonged 
use should be remembered. 

In cases which have resisted all local applications the 
affected areas of mucous membrane have been excised. 
Even this method, however, does not promise certain 
cure. It should be tried, however, when the pruritus is 
localized and has resisted the milder forms of treat- 
ment. 

Kraurosis Vulvae. — Kraurosis vulvae is a very rare 
disease, of chronic inflammatory nature, affecting the 
vulva. The disease is characterized by cutaneous 
atrophy, with very marked shrinking and contraction of 



DISEASES OF THE EXTERNAL GENITALS. 45 

the vaginal orifice. The lesions may be unilateral or 
circumscribed, but usually the tissues of the labia majora, 
the nymphse, and the area surrounding the clitoris and 
urinary meatus are more or less involved. The cause of 
the disease has not as yet been determined. It has been 
observed at every age after puberty, in the nulliparae as 
well as the multiparas, and in the parturient woman. It 
must be differentiated from pruritus and the atrophic 
changes which take place after the physiological and 
induced menopause. 

The first symptoms noticed by the patient are usually 
those of pruritus — an intense itching and burning about 
the vulva. In some cases the affected tissue early 
becomes excessively hyperplastic. The mucous mem- 
brane and the skin of the vulva are often discolored, 
small red spots appearing, which are sensitive to touch. 
Later a peculiar shrinking of the superficial tissue takes 
place, and the diseased surfaces become dry and whit- 
ened. The nymphae gradually disappear, fusing with 
the labia majora ; and the mucous membrane and skin 
become shiny and drawn smoothly over the shrunken 
clitoris. Cracks or fissures appear on the dry surfaces. 
A sensation of drawing and shrinking of the vulva is 
now usually experienced. The- vaginal orifice gradually 
narrows and contracts, until frequently the little finger 
can scarcely be introduced. When this last condition of 
atrophy is reached, the pathological process is arrested, 
the subjective sensations of shrinking pass away, and the 
symptoms resembling pruritus are no longer experienced. 
The shrunken and contracted vaginal orifice, however, 
persists and is never spontaneously restored. 

Treatment. — Palliative treatment by local applications 
may be tried, or a cure may be attempted by operation. 
The palliative treatment is simply directed toward the 
relief of the subjective symptoms, which at times are 
exceedingly painful. Pure carbolic acid or a solution of 
cocaine applied locally, or pure nitrate of silver applica- 
tions frequently repeated, afford temporary relief Cloths 



46 A TEXT-BOOK OF DISEASES OF WOMEN. 

wrung out of hot water and placed over the vulva also 
lessen the suffering. A solution of the neutral acetate 
of lead in glycerin, on cotton placed between the labia, 
is recommended. Forced dilatation of the vaginal orifice 
under ether has been practised with good result. The 
most satisfactory treatment is complete excision of the 
diseased tissue. Unless all affected tissue is removed, 
the disease may return. 

Varicose Tumors of the Vulva. — Varicose tumors 
of the vulva are usually the result of pregnancy. They 
may, however, accompany any form of pelvic or abdom- 
inal tumor, the pressure of which interferes with the ven- 
ous circulation of the pelvis. The varicose condition 
usually affects the labia majora. It varies from a mere 
increase in size of the veins of the vulva to a varicose 
tumor the size of the fetal head. The condition, being 
secondary, usually disappears with the removal of the 
exciting cause. The labia may be supported with a 
compress and a bandage. 

Hematoma of the Vulva. — Hematoma of the vulva 
is due to the subcutaneous rupture of a vein. Blows, 
kicks, or falls cause this condition. It is usually pro- 
duced by rupture of a varicose vein during pregnancy or 
labor. 

The affected labium is purple in color and may reach 
the size of a fetal head. When the hematoma is small 
the vagina should be kept as clean and aseptic as possi- 
ble, and a light compress should be applied. Absorption 
usually takes place. If the collection of blood is large 
or if it has become infected, a free incision should be 
made into the labium, the clots should be turned out, and 
the cavity thoroughly washed and packed with gauze. 

Papilloma. — Papillomata or warts of the vulva are not 
uncommon. They may occur singly, scattered over the 
vulva and the neighboring skin, and extending up the va- 
gina as far as the cervix uteri, or they may occur in large 
cauliflower-like masses. They are pink or purplish in 
color. They often exude a bloody, offensive discharge, 



DISEASES OF THE EXTERNAL GENITALS, 47 

which is capable of exciting a similar condition by con- 
tact. Papilloma is usually the result of gonorrhea or 
syphilis. It may, however, be caused by irritation from 
filth or by the leucorrhea of pregnancy. 

The treatment of papilloma is by excision. The small 
warts should be picked up with forceps and clipped off 
with curved scissors. Every one should be removed or 
the condition may recur. In the case of large papil- 
lomatous tumors the wound of excision should be closed 
with continuous sutures. Pregnancy is no contraindica- 
tion to excision of papillomata. 

The vulva may be the seat of epithelioma, lupus, sar- 
coma, fibroma, fibromyoma, myxoma, lipoma, or enchon- 
droma. These tumors present the same characteristics 
and demand the same surgical treatment as in other parts 
of the body. 

Small cysts have been found in the labia majora and 
minora, the vestibule, the hymen, and the clitoris. 

Elephantiasis. — True elephantiasis of the vulva (ele- 
phantiasis Arabum), due to the presence of the Filaria 
sanguinis hominis, is a rare disease in this climate. 
The disease occurs especially in Barbadoes. It may 
affect the labia and the clitoris. The hypertrophied 
labia may attain the size of the adult head. 

The treatment of this condition is excision of the 
affected structures. 

There is a syphilitic form of hypertrophy or elephan- 
tiasis of the vulva which is not uncommon in this 
country. The labia minora and majora may be trans- 
formed into enormous flap-like folds. Though at first 
free from ulceration, this may subsequently result from 
chafing. Warty growths may cover the hypertrophied 
labia, the perineum, and the buttocks. The disease 
usually affects both labia, though it may be confined 
to one. 

This manifestation of syphilis does not yield readily to 
constitutional or local medicinal treatment. Many cases 
prove to be incurable by medicine. Antisyphilitic treat- 



48 A TEXT-BOOK OF DISEASES OF WOMEN. 

ment should always be tried at first, and if this fails, the 
hypertrophied structures should be excised with the knife. 

If, in such cases, there is any doubt in regard to diag- 
nosis between syphilis and cancer, a small portion of 
tissue should be excised and submitted to microscopic 
examination. 

Adhesions of the Clitoris. — Adhesions between the 
glans of the clitoris and the. prepuce or hood which 
covers it are exceedingly common. Usually no trouble 
whatever is caused by these adhesions, unless an accu- 
mulation of smegma takes place, or irritation is produced 
by the presence of a concretion. 

In case of any irritation about the genitals, the prepuce 
and clitoris should always be carefully examined. In 
fact, a careful examination of the clitoris should form a 
routine part of all examinations of the external genitals. 

When trouble arises from the presence of adhesions, 
the prepuce should be drawn back and the adhesions 
freed with a blunt probe. A 20 per cent, solution of 
cocaine should be applied to the clitoris for ten minutes 
previous to the operation. The whole corona and the 
sulcus back of the corona should be exposed. The raw 
surface should be covered with vaseline, and the patient 
should abstain from walking as long as pain is caused by 
it. The prepuce should be drawn back and vaseline 
applied every day for two weeks, to prevent the formation 
of adhesions. 



CHAPTER IV. 
DISEASES OF THE VAGINA. 

Inflammation of the Vagina. — Acute inflammation 
of the vagina is not a very common affection. Primary 
inflammation confined to the vagina alone is unusual. 
The disease in most cases is secondary to vulvitis, ure- 
thritis, or endo-cervicitis. The causes of vulvitis (which 
have already been considered) are also the causes of 
vaginitis. It is of importance to remember that the dis- 
ease may occur in children as a result of the same factors 
which produce vulvitis. 

The exanthemata, as measles and scarlet fever, may 
cause vaginitis as part of the general involvement of the 
skin and mucous membrane which occurs in these dis- 
eases. The most usual cause is gonorrhea. 

Several varieties of acute vaginitis may be recognized — 
the simple, the granular, the senile, and the emphysem- 
atous. It is unusual to find the entire surface of the 
vagina involved. The disease is confined to areas or 
patches separated by healthy tissue. 

In simple vaginitis the inflamed membrane remains 
smooth. 

In granular vaginitis, which is the variety usually seen, 
the papillae are infiltrated with small cells, and are much 
enlarged, so that the inflamed surface has a granular 
appearance. 

Senile vaginitis is due to infection of portions of the 
vaginal mucous membrane that have lost their epithelium 
as a result of the atrophic changes of old age. This dis- 
ease occurs in patches of various size, sometimes present- 
ing the character of ecchymosis; in other cases the 

4 L9 



5° A TEXT-BOOK OF DISEASES OF WOMEN. 

patches have altogether lost the epithelium, and perma- 
nent adhesions may take place between areas which are 
brought in contact. This form of vaginitis has also been 
called adhesive vaginitis. It is said that a similar con- 
dition may occur in children. 

The emphysematous form of vaginitis occurs in preg- 
nancy. The vaginal walls are swollen and crepitating. 
The gas is contained in the meshes of the connective 
tissue. 

Acute vaginitis is accompanied by dull pain and a 
sense of fulness in the pelvis. The discomfort is in- 
creased by standing, walking, defecation, and urination. 
There is a free discharge of serum or pus, which may be 
tinged with blood. The character of the discharge 
depends upon the variety and the period of the disease. 
Inspection, which can best be made through the Sims 
speculum, with the woman in the Sims or knee-chest 
position, shows the characteristic lesions of inflammation 
of the mucous membrane. 

Acute vaginitis, if neglected, may pass into the chronic 
form. It usually lingers in the upper part of the vagina, 
in the fornices, especially in vaginitis of gonorrheal 
origin. By careful inspection we find here one or more 
granular patches of inflammation, which cause a vaginal 
discharge from which man may be infected, and from 
which infection of the upper portion of the genital tract, 
the uterus, and the Fallopian tubes may be derived. 

Treatment. — Vaginitis, especially of the gonorrheal 
form, should be treated vigorously, and treatment should 
be continued until all traces of inflammation have dis- 
appeared. Inflammation of any part of the lower portion 
of the genital tract may have the most disastrous conse- 
quences if it extends to the uterus and the Fallopian 
tubes. 

The woman should be kept as quiet as possible. The 
bowels should be moved freely with saline purgatives. 
She should take, three times in twenty-four hours, lying 
upon her back, a vaginal douche of one gallon of a bo- 



DISEASES OF THE VAGINA. 5 1 

racic-acid solution (3J to the pint). The temperature of 
the solution should be about no° F. 

If the disease be of gonorrheal origin, a warm bichloride 
solution (i : 5000) should be used in the same way. 

After the acute symptoms have subsided local applica- 
tions should be made, in addition to the douches. The 
woman should be placed in the knee-chest position, and 
the vagina should be thoroughly exposed with the Sims 
speculum. If necessary, the vaginal surface should be 
gently cleaned with warm water and cotton. A 4 per 
cent, solution of cocaine may be applied to the vagina if 
there is. much pain. Then the entire vaginal surface 
should be painted with a solution of bichloride of mer- 
cury (1 : 1000). These applications should be made 
daily until the disease is cured. The vaginal douches 
should be continued at the same time. 

In the chronic form of the disease and in senile vagi- 
nitis the local patches of inflammation should be painted 
once a day with a solution of nitrate of silver, 5 to 10 
per cent., or stronger if the condition does not yield. 
The senile form of vaginitis, being dependent upon a 
general condition, is often impossible to cure. We can 
sometimes relieve the discomfort by applying boracic- 
acid ointment (3J to §j) to the vagina. The application 
of pure carbolic acid to the inflamed patches sometimes 
does good. 

Urethritis usually accompanies a gonorrheal vaginitis, 
and demands coincident treatment. 

Tumors of the Vagina. — Vaginal Cysts. — Well-de- 
fined cysts are sometimes found in the vaginal walls. 
They occur at all ages from childhood to old age. 

Vaginal cysts are usually single. They vary in size 
from that of a pea to that of a fetal head. The vaginal 
mucous membrane covers the free surface of the cyst, 
and may either be movable over it or may be much at- 
tenuated and closely incorporated with the cyst-wall. 
Vaginal cysts may be sessile or more or less pedunculated. 
The internal surface of the cvst is usually covered with 



52 A TEXT-BOOK OF DISEASES OF WOMEN. 

cylindrical epithelium, which is sometimes ciliated. The 
contents vary in consistency and color. They are often 
viscid, transparent, and of a pale yellow tint. They may 
contain pus or altered blood. 

The origin of vaginal cysts has been much disputed. 
It is probable that they arise from the remains of the 
Wolffian canal — the canal of Gartner. In the embryo 
the transverse or longitudinal tubule of the parovarium 
extends to the side of the uterus and thence down the 
side of the vagina to the urethral orifice. It persists in 
this condition in some of the lower animals — the sow and 
the cow — and may also persist as a closed tube in woman. 
In such cases it may become distended and form the 
vaginal cyst. 

The treatment of vaginal cyst is removal. If the tu- 
mor be situated near the vulva, it may be extirpated by 
careful dissection. If this operation be deemed imprac- 
ticable, partial excision of the cyst should be practised. 
The tumor should be seized with a tenaculum, opened by 
the scissors, and part of the wall, with the overlying 
mucous membrane, should be excised. The interior of 
the cyst should then be packed with gauze. 

Fibroid Tumors of the Vagina. — Fibroid tumors some- 
times occur in the vagina. They are usually found in 
the upper part of the anterior wall. They are sometimes 
adherent to the urethra. They are usually of small size, 
but may attain a diameter of six inches. The treatment 
of such tumors is removal. 

Cancer and sarcoma may attack the vagina, though 
these diseases as primary conditions are very rare. When 
possible, complete removal should be done. 

Atresia of the Vagina. — Severe puerperal infection 
or mechanical injury, followed by extensive destruction 
of the tissues of the vagina, may result in a cicatricial 
narrowing or complete closure or atresia of the vaginal 
canal. 

The symptoms of this condition are due to retention 
of the uterine discharges. There is no discharge of 



DISEASES OF THE VAGINA. 53 

menstrual blood from the vagina. Attacks of pain occur 
periodically at the menstrual periods. A cystic tumor, 
which may be felt by rectal examination, is present. 
The tumor consists of the distended portion of the 
vaginal canal (hematocolpos), and sometimes of the dis- 
tended cervical canal and body of the uterus. The con- 
tents of the hematocolpos are usually sterile, although 
they may become purulent (pyocolpos). 

The diagnosis is readily made by vaginal and rectal 
examination. 

Treatment consists in incision and excision of the 
vaginal septum and the suture of the vaginal mucous 
membrane above to that below the obstruction. In very 
severe cases it is difficult to maintain the patulous condi- 
tion of the vaginal canal on account of subsequent cica- 
tricial contraction. In such cases the repeated passage 
of vaginal bougies or the transplantation of mucous mem- 
brane has been resorted to 

Vaginismus. — The term "vaginismus" has been ap- 
plied to a condition characterized by a spasmodic contrac- 
tion of the muscles which close the vaginal orifice. The 
muscular spasm occurs reflexly when penetration of the 
vagina is attempted, as at coitus or a digital examina- 
tion. The condition is due to dread of pain, and is 
usually the result of some painful local lesion, such as 
a urethral caruncle, fissures or sores of the vulva or 
anus, etc. ; or it may be due to some painful condition of 
the tubes and ovaries. Similar contraction is observed 
in the sphincters of the anus when there is present a 
painful anal le&ion. 

Vaginismus has been said to occur in neurotic and hys- 
teric women in whom there was no discoverable local 
lesion. 

Treatment consists in the removal of any local cause 
of pain or irritation. 

If the reflex spasm of the muscles persists when coitus 
is attempted, notwithstanding the removal or the absence 



54 A TEXT-BOOK OF DISEASES OF WOMEN. 

of any discoverable local cause, operative measures have 
been advised. 

Under anesthesia the vaginal entrance has been 
stretched by means of large dilators or the fingers, or 
the fibers of the sphincter vaginae have been cut on each 
side of the fourchette and a glass or vulcanite tube of 
suitable size has then been placed in the vagina and 
retained for two or three weeks by a perineal pad and T- 
bandage. 

Vaginismus is a very rare condition. Operative treat- 
ment, except that which may be required for the removal 
of some local cause of irritation, is rarely, if ever, neces- 
sary. 

Coccygodynia. — Coccygodynia is a rare affection char- 
acterized by pain in the coccyx and surrounding struc- 
tures. The pain is caused by pressure, as in sitting, or 
by any movement involving the muscles attached to the 
coccyx. The disease is usually caused by traumatism, 
and in most cases is due to injuries to the coccyx in 
labor, as a result of which the bone is fractured or dislo- 
cated, and becomes fixed in an abnormal position. Some- 
times osteitis or necrosis develops. In the unusual cases, 
in which no structural changes are detected, the condition 
may be due to rheumatism. Coccygodynia is very rarely 
found in men. 

The diagnosis may be made by introducing the index 
finger in the rectum and palpating the anterior and lat- 
eral surfaces of the coccyx, and by moving the bone 
between the finger in the rectum and the thumb placed 
in the crease of the nates. The mobility, deformity, and 
tenderness may be readily determined. If a local lesion 
is found, and the symptoms have not yielded within a 
reasonable time to expectant treatment, removal of the 
coccyx by operation is indicated. The coccyx is exposed 
by a median incision, the bone is separated from its mus- 
cular and tendinous attachments, and is removed at the 
sacrococcygeal articulation with scalpel or scissors. If 



DISEASES OF THE VAGINA. 55 

the articulation is ankylosed, it may be necessary to use 
the chain-saw. The wound is drained with a few strands 
of silkworm-gut and closed with interrupted sutures. 

Operation should not be advised hastily. The painful 
symptoms are not always relieved by it. Operation should 
not be performed unless bony deformity or other distinct 
lesion is found. 



CHAPTER V. 
ANATOMY AND MECHANISM OF THE PERINEUM. 

An accurate knowledge of the anatomy and mechanism 
of the female perineum is essential to an understanding 
of the nature and treatment of injuries to this structure. 
The anatomical structures lying between the anus behind 




External superficial 
perineal nerve. 

Internal superficial 
perineal nerve. 

Superior perineal 
artery. 

Inferior pudendal 
nerve. 



Pudic nerve. 

Internal pudic 
artery. 

Inferior hemor- 
rhoidal artery. 

Inferior iiemor- 
rhoidal nerve. 

Tendinous center of 
perineum. 



Coccyx. 
Fig. 18, A. — Superficial structures of the female perineum (Weisse). 

and the symphysis pubis in front are those that most 
directly interest the gynecologist. Proceeding from 

56 



ANATOMY OF THE PERINEUM. 



57 



below upward, we find the following structures lying in 
superimposed planes: the skin, the superficial fascia, the 
deep layer of the superficial fascia, the transversus perinaei 
and the sphincter vaginae muscles, the anterior layer of 
the triangular ligament, the posterior layer of the trian- 
gular ligament, the levator ani muscle (Fig. 19). 

The vagina passes through these structures. They 
surround and support the ostium vaginae as the fascia 
and muscles surround and support the opening of the 




Dorsal vein of clit- 
oris. 

Dorsal artery of clit- 
oris. 

Inferior pudendal 
nerve. 

Artery of bulb. 



Pudic nerve. 

Internal pudic 
artery. 

Inferior hemor- 
rhoidal artery. 

Inferior hemor- 
rhoidal nerve. 

Tendinous perineal 
center. 

Superfcial trans- 
versus perincei 

muscle. 



Fig. 19. — Dissection of female perineum : on the left side the perineal mus- 
cles are exposed by the reflection of the perineal fascia; on the right side the 
muscles and the superficial layer of the triangular ligament have been removed, 
thereby exposing the deep layer of the ligament. S. V, Sphincter vaginae muscle. 



rectum or the anus. The muscles and fasciae are 
attached in the median line between the anus and the 
vagina, and therefore this part of the body, which is 
called the perineum, is supported or maintained in its 



58 



A TEXT-BOOK OF DISEASES OF WOMEN. 



proper position by these various structures. The trans- 
versa perinsei arises from the ramus of the ischium and 
is inserted in the perineum. The bulbo-cavernosus, or 
sphincter vaginae, arises in the perineum and is inserted 
in and about the clitoris. The inner fibers of the levator 
ani arise from the symphysis pubis and are inserted in 
the perineum and the lower part of the vagina (Fig. 20). 




Fig. 20. — Dissection of female perineum, showing the deeper structures after 
removal of the levator and sphincter ani muscles. 



When these muscles contract, their action, therefore, is 
to draw the perineum upward and forward. At the same 
time the anus is drawn upward and forward, and so also 
is the posterior margin of the ostium vaginae and the 
lower portion of the posterior vaginal wall. 

The vagina has no circular sphincter like the anus, but 



ANATOMY OF THE PERINEUM. 



59 



the vaginal mouth is kept closed by the action of the 
transversus perinaei, sphincter vaginae, and levator ani 
muscles, which draw the perineum forward, and thus 
keep the posterior vaginal wall in apposition with the 
anterior wall. 

This sling of muscles and fascia, which surrounds and 
supports the opening of the vagina, may readily be felt in 




Fig. 21. — Muscular floor of the pelvis seen from above. 



the nulliparous woman by introducing the finger in the 
vagina and pressing backward and outward toward the 
ischio-rectal fossa. We then feel plainly, immediately 
within the ostium vaginae, a firm resisting band of tissue, 
apparently about half an inch broad, embracing the pos- 
terior portion of the lower vagina. This band is formed 
by the inner edges of the various muscles and planes oi 
fascia that have been described. 

The vagina extends, as a transverse slit in the pelvic 
floor, upward and backward, approximately in the direc- 



60 A TEXT-BOOK OF DISEASES OF WOMEN. 

tion of a line drawn from the ostium vaginae to the 
fifth sacral vertebra. It is approximately parallel with 
the conjugate of the brim, so that when the woman is 
erect the long axis of the vagina is inclined at an angle 




Fig. 22. — Sagittal section showing relations of the several layers of fascia within 
the pelvic floor (Dickinson). 



of 6o° to the horizon. The vagina is not a vertical open 
tube: it is a slit in the pelvic floor, in health always 
closed by the accurate apposition of the anterior and pos- 
terior walls (Fig. 21). The anterior vaginal wall is about 
2% inches long in a vertical mesial line. The posterior 



vaginal wall is about 3^ inches long. The vaginal walls 
are triangular in shape, being broader above than below. 
The shape of the normal vagina at the pelvic outlet is 
shown by Fig. 23. The section here shows the vaginal 






ANATOMY OF THE PERINEUM. 



6l 



slit of the shape of the letter H. The portions of the 
slit extending backward and somewhat outward are 




FlG. 23. — Section illustrating the characteristic form of the vaginal cleft 
(Henle) : Ua, urethra; Va, vagina ; L, levator ani; R, rectum. 

called the vaginal sulci or furrows. They are directions 
of diminished resistance in which tears are liable to 
occur. 



CHAPTER VI. 
INJURIES TO THE PERINEUM. 

The injuries to the perineum that may result from 
childbirth are classified according to the position or the 
direction and extent of the laceration. They are as 
follows: slight median tear; median tear involving the 
sphincter ani; tear in one or both of the vaginal sulci; 
subcutaneous laceration of the muscles and fascia. 

All these injuries demand operative treatment. The 
operation for the repair of injuries to the perineum is 
called perineorrhaphy. It is called immediate or pri- 
mary, intermediate, and secondary perineorrhaphy, ac- 
cording to the time after the receipt of the injury at 
which the operation is performed. The primary operation 
is done during the first twenty-four hours. The primary 
operation should always be performed. A careful inspec- 
tion of the perineum and the posterior vaginal wall should 
always be made after labor, and any laceration should 
be repaired within twenty-four hours. The advantages 
of the primary operation are many. The parts are 
usually so numb that it is not necessary to administer an 
anesthetic. No denudation is necessary, and therefore 
no tissue need be sacrificed. The woman is spared the 
pain and discomfort of granulation and cicatrization. 

The bad results that follow neglect of the primary 
operation are very numerous, and will be studied here- 
after. The injured muscles retract, and, being function- 
ally useless, undergo atrophy, and when finally repaired 
never possess their former strength. Involution in the 
vagina and the uterus may be arrested, and all the disas- 
ters incident to subinvolution may appear. Vaginal 
and uterine prolapse occur; the natural supports of the 

62 



INJURIES TO THE PERINEUM. 63 

vagina and uterus become stretched, and, though after- 
ward the perineum may be restored, yet it may be found 
impossible to retain the uterus in its proper position. It 
is always good surgery to repair an injury as soon as 
possible. 

When practicable, a certain amount of preparation of 
the patient should be made before the operation of per- 
ineorrhaphy. This is most easily effected before the 
intermediate and secondary operations. The vagina 
and the vulva should be sterilized, and the intestinal 
tract should be emptied. Thorough evacuation of the 
bowels is most important when the sphincter ani has 
been injured, because it is desirable, after operation 
for this lesion, that the bowels should not be moved for 
five or six days. A saline purgative should be admin- 
istered on an empty stomach about five hours before the 
operation, and a rectal injection of soap and water 
should be administered about one hour before the ope- 
ration. Whatever purgative be employed, it should be 
administered at such a time that its action shall have 
ceased by the time of the operation. If this precau- 
tion is not observed, there may be a discharge of feces 
that will infect the wound and interfere with the man- 
ipulations. 

For operation upon the perineum the woman should 
be placed in the dorso-sacral position (Fig. 1, page 23). 

The intermediate operation is performed during the 
granulation period — ten days or two weeks after labor. 
At this time the raw surfaces are covered with granula- 
tion-tissue and bathed with pus. The edges of the wound 
and the surrounding tissue may be hard and swollen 
from infiltration with inflammatory products. In the in- 
termediate operation it is necessary to administer an anes- 
thetic or to anesthetize the parts locally with a 10 per 
cent, solution of cocaine. 

All cicatricial tissue, granulation-tissue, and rough 
edges should be scraped away with the knife, the scis- 
sors, or the curet. The raw surfaces should be thor- 



6 4 



A TEXT-BOOK OF DISEASES OF WOMEN. 



oughly washed with a 50 per cent, solution of peroxide 
of hydrogen and a 1 : 1000 solution of bichloride of mer- 
cury. The sutures should then be introduced. 

The secondary operation is performed at any time after 
cicatrization has occurred — often many years after the 
receipt of the injury. This operation is at present one 
of the commonest in gynecology, because the injury is 
not detected, is neglected, or is improperly repaired after 
labor. In the secondary operation an anesthetic is neces- 




Fig. 24. — Emmet's perineal scissors. 



sary. The mucous membrane must be removed or de- 
nuded on the posterior wall and about the mouth of the 
vagina, in order that the lacerated structures may be 
brought again in apposition. The denudation is best 




Fig. 25. — Curved scissors for denuding. 

made by means of scissors curved on the flat (Figs. 24 
and 25). 




Fig. 26. — Tenacula for plastic operations. 

The strip of mucous membrane to be removed is picked 
up with a tenaculum (Fig. 26) or with tissue forceps 



INJURIES TO THE PERINEUM. 



65 



(Fig. 27); the scissors are placed with the blades parallel 
to the surface to be denuded, and the strip is cut away 



Fig. 27. — Tissue-forceps. 

evenly, in one piece if possible. A similar contiguous 
strip is removed, and so on until the necessary surface is 




Fig. 28. — Sponge -holder. 



bare. Sponges in holders (Fig. 28) or continuous irri- 
gation may be used to remove blood. 

For all operations on the perineum round-pointed 
needles curved at the tip should be used (Fig. 29). The 
tissues are always sufficiently soft for the 
passage of such a needle. A needle with 
a cutting edge is unnecessary and may 
increase the bleeding. 

The needle may be held in any kind 
of needle-holder preferred. The Emmet 
needle-holder (Fig. 30) is very conve- 
nient. 

The point of the needle should be 
guided and held by the tenaculum. The 
tenaculum must always be held in a 
plane parallel with the plane of the 



Fig. 29. — Emmet's 
perineal needle. 




Fig. 30. — Emmet's needle-holder. 

needle-holder ; otherwise the needle-point may escape 
from the embrace of the tenaculum. 
5 



66 A TEXT-BOOK OF DISEASES OF WOMEN. 

Silver wire and silkworm gut are the best sutures in 
the operation of perineorrhaphy. 

The suture is conveniently attached to the needle by 
means of a silk carrier (Fig. 31). 




Fig. 31. — Perineal needle with silk carrier. 

The sutures may be fastened by passing the ends 
through a perforated shot which is slipped down to the 
line of union and compressed by the shot-compressor 
(Fig. 32). All blood should be carefully removed from 




Shot-compressor. 



the surfaces that are brought together. The sutures 
should only be sufficiently tense to produce accurate ap- 
position. A light gauze drain should be introduced in 
the vagina, and should be removed in forty-eight hours. 
iVfterward one vaginal douche of about a quart of warm 
bichloride solution (1 : 2000) should be administered every 
day. After the douche the labia should be separated and 
the vagina carefully dried by cotton held in dressing-for- 
ceps. Except in those cases in which the sphincter ani 
is involved, the bowels may be moved on the second or 
third day. The woman should stay in bed for two weeks, 
at the end of which time the sutures should be removed. 



INJURIES TO THE PERINEUM. 



6 7 



She should avoid heavy lifting, long standing, and bi- 
cycle- or horseback-riding for two months after the ope- 
ration. Constipation should always be avoided. Coitus 
may be resumed six weeks after operation. 

The special forms of operation will be discussed in the 
consideration of the varieties of perineal injury. 

Slight Median laceration of the Perineum. — In 
this injury the tear takes place through the fourchette. 
Posteriorly it may extend 
as far as the sphincter ani 
muscle. Upward it may 
extend for an inch up the 
posterior vaginal wall. The 
appearance of this tear is 
shown in Fig. 33. It will 
be noted that, as this tear 
takes place in the median 
line, none of the muscles 
that support the perineum 
are involved, nor are the 
planes of fascia injured. 
The perineum is slightly 
split, and the insertions and 
origins of the muscles and 
the fascia are slightly sep- 
arated. The supporting 
structures of the perineum 
and the pelvic floor are, 
however, uninjured. 

If this tear is detected 
after labor, it should be closed by the immediate opera- 
tion. A slight tear involving chiefly the cutaneous 
aspect of the perineum should be closed by three or four 
sutures introduced from the outside, as in Fig. i>3- The 
needle should be introduced about a quarter of an inch 
from the edge of the wound. It should not be passed 
parallel with the plane of the lacerated surface, but 
should be swept outward and then inward toward the 




Fig. 3; 



-Recent slight median 



laceration of the perineum 
introduced. 



sutures 



68 A TEXT-BOOK OF DISEASES OF WOMEN. 

angle at the bottom of the tear (Fig. 34). It may either 
emerge at the angle and be re-introduced, or it may be 



Correct. 



\ I 

\ J 
» f 


/ s* Incorrect. 




/j 



Fig. 34. — Diagram representing the correct and the incorrect method of passing 
the suture for closure of slight perineal laceration. 

passed directly through to the skin-margin on the oppo- 
site side of the wound. If 
the suture is passed in this 
way, there will be perfect ap- 
position throughout the whole 
surface of laceration. If the 
sutures are improperly passed, 
there may result only apposi- 
tion of the skin-edges. 

If the laceration extends 
up the posterior vaginal wall, 
two sets of sutures must be 
introduced — one on the vag- 
inal aspect of the tear, and 
one on the skin aspect (Fig. 

35)- 

The secondary operation 

of perineorrhaphy is not in- 
dicated in slight median 
lacerations of the perineum 
that may have been neglected 
at the time of labor, as the 
integrity of the pelvic floor 
is practically unaffected by 
them. 
Median Tear involving the Sphincter Ani. — In this 




Recent slight median 



laceration of the perineum extend- 
ing up the posterior vaginal wall : 
sutures introduced on the vaginal 
and cutaneous aspects. 



INJURIES TO THE PERINEUM. 69 

form of injury the laceration takes place in the median 
line and extends backward through the sphincter ani 
muscle, and perhaps upward for one or more inches 
through the recto-vaginal septum. Permanent inconti- 
nence of feces results. 

Though this is a most extensive injury attended by 
most unpleasant results, yet it will be seen that none of 
the supporting structures (the fascia and the muscles) that 
support the pelvic floor are injured by it. 

The perineum is split in the middle, but the muscles 
attached to it, being uninjured, are still able to draw the 
two halves of the perineum forward, thus supporting the 
posterior vaginal wall and keeping the vagina closed. 
There is but very little tendency to separation of the two 
parts of the split perineum by lateral traction, the only 
muscle that acts at all in this direction being the feeble 
transverse perineal muscle. 

Therefore, though there is loss of power of the sphinc- 
ter ani muscle, yet in this injury the woman may not 
suffer any of the consequences of loss of power in the 
support of the pelvic floor, such as vaginal and uterine 
prolapse. 

After laceration of the perineum through the sphincter 
ani the divided muscle retracts so that it embraces only 
the posterior margin of the anus. If the injury be not 
repaired immediately, retraction and atrophy progress, so 
that in time the sphincter muscle, lying posterior to the 
anal opening, may be but half an inch in length and of 
very much less than its normal thickness. Cicatrization 
takes place, and the parts present the appearance shown 
in Fig. 37. 

Notwithstanding the atrophy and retraction of the 
muscle, continence may be re-established by operation, 
though many years may have elapsed since the receipt oi 
the injury. 

Notwithstanding the very obvious reasons for the per- 
formance of the immediate operation for the relief oi 
this condition, it is yet very often neglected, and the 



70 A TEXT-BOOK OF DISEASES OF WOMEN. 



gynecologist is called upon to repair the injury many 
years after its occurrence. 

The important part of the operation for this injury 
consists in the repair of the muscle. In many operations 

the recto-vaginal septum 
is repaired and the cutane- 
ous portion of the peri- 
neum is repaired, but the 
operator fails to secure in 
his sutures the sphincter 
ani muscle, and conse- 
quently the incontinence 
is not cured (see Fig. 36). 
The mistake often made is 
that the sutures that are 
introduced to close the an- 
terior margin of the anus 
are inserted too far forward 
and too far out to catch 
the ends of the sphincter 
ani muscle, which has re- 
tracted so that, in some 
cases, it lies altogether be- 
hind the anal opening. 
Or, perhaps, only the outer fibers of the sphincter ani are 
included in the suture, and partial incontinence results. 
The position of the sphincter ani muscle is indicated 
by the corrugated or wrinkled skin overlying it. The 
ends of the muscles, being retracted, do not lie in the 
plane of the laceration, but their position is marked by 
a depression or dimple (Fig. 37). 

The technique of the primary operation is included in 
a consideration of that of the secondary operation, the 
only difference being that in the latter operation denuda- 
tion is necessary. 

The parts should first be denuded, so that they present 
the same raw surface that was exposed in the original 
laceration. 




Fig. 36. — Imperfect repair of the 
sphincter ani. The muscle has not 
been included by the sutures, and does 
not surround the anal opening. 



INJURIES TO THE PERINEUM. 



71 



In removing tissue attached to 



The lower end of the recto-vaginal septum that forms 
the anterior margin of the anal opening is usually thin 
and cicatricial where the mucous membranes of the 
vagina and rectum unite. All this cicatricial tissue 
should be cut away, and the mucous membrane of the 
vagina may be drawn forward and separated by dissection 
from the mucous membrane of the rectum, in order to 
make a somewhat broader surface through which to pass 
the sutures. 

Special care should be directed to the denudation of 
the ends of the sphincter muscle. The tissue lying at 
the bottom of the depression that marks the end of the 
sphincter should be picked up with forceps or a tenaculum 
and carefully cut away, 
the mucous membrane 
of the rectum the opera- 
tor should avoid cutting 
the healthy portion of 
this mucous membrane, 
as bleeding from it is 
often annoying. 

The first suture should 
be introduced at the mar- 
gin of the anal opening, 
within the area of corru- 
gated skin that marks the 
position of the muscle, 
and behind the depres- 
sion that marks the end 
of the muscle. The end 
of the muscle may be 
seized with a tenaculum 
or with tissue-forceps and 
drawn out to ensure that 
the suture includes mus- 
cular tissue. The needle 
is then passed near the edge of the rectal mucous mem- 
brane to the apex of the tear in the recto-vaginal septum, 




the sphincter ani. The sphincter muscle 
lies behind the anal opening. Its position 
is indicated by the wrinkled skin; its ends 
are marked by the depressions on each 
side of the anal opening. 



7 2 



A TEXT-BOOK OF DISEASES OF WOMEN. 



whence it emerges. It is re-introduced here, and passed 
in a similar manner to emerge upon the opposite side, 
behind the other end of the sphincter ani muscle (Fig. 
38). This suture is introduced very near the edge of 
the wound, so that there may not be any inversion of 
skin to prevent perfect apposition of the ends of the 
muscle. In case there has been much retraction of 
the sphincter ani muscle, the ends of the suture may 
appear to lie behind the anal opening. The second 



&\ 




% 


ffiflM * 


llv £ '*''• 


■ ^T^ 


r ifi 


*\ V 




^ •- 


fit 





Fig. 38. — Denudation and su- Fig. 39. — Completed operation. The 

tures for repair of laceration. The anal opening is surrounded by the sphinc- 

two posterior sutures pass through ter. One shot has disappeared in the 

the sphincter muscle. anus. The anterior suture is omitted. 



suture is introduced somewhat outside of the first — still, 
however, within the area of the sphincter muscle — and 
is passed in a similar manner to emerge in the apex of 
the recto-vaginal tear anterior to the first suture. The 
remaining sutures to close the perineum are passed as 
already described in the operation for slight median tear 
of the perineum. When the sutures are shotted, great 



INJURIES TO THE PERINEUM. 



n 



care must be exercised in making perfect apposition of 
the parts brought together by the first two sutures. 
Sometimes such apposition is more easily secured by 
shotting the anterior perineal sutures first. When the 
operation is completed the first suture through the 
sphincter is sometimes drawn upward, so that it disap- 
pears in the anal opening. If the muscle has been prop- 
erly secured, it will be observed that the anal opening 
is surrounded by the ring of wrinkled or corrugated skin 

(Fig. 39)- 

After this operation the bowels should not be moved 
for five or six days. The intestinal contents should 
then be rendered as soft as possible by the administra- 
tion of small repeated doses of some saline purgative, 
as Rochelle salts 3J, every hour for five or six hours. 
If the woman feels that she may have difficulty in 
having a passage, a rectal injection of a pint of soapsuds 
and warm water should be 
very carefully adminis- 
tered. The nozzle of the 
syringe should be well 
greased and passed along 
the posterior margin of 
the anal opening. After 
this the bowels should be 
moved every forty-eight 
hours. The sutures should 
be removed at the end of 
two weeks. 

laceration through 
the Sphincter Ani, in- 
volving the Recto-vag- 
inal Septum. — In case 
the recto-vaginal septum 
has been torn, it may be 
necessary to repair the 
tear before operating on 
the perineum and the sphincter ani muscle 




Fig. 40. — Laceration through the 

sphincter ani, extending up the recto- 
vaginal septum. 



In some 



74 



A TEXT-BOOK OF DISEASES OF WOMEN. 



cases the laceration extends for three or more inches up 
the septum (Fig. 40). 

The edges of the septal tear should be denuded, the 
strip of tissue being cut away to the line of normal rectal 
mucous membrane. Annoying bleeding may occur if the 
mucous membrane of the rectum is injured. The denu- 
dation may be extended on the vaginal aspect as far as is 
necessary to obtain a sufficiently broad surface for approxi- 
mation. 

The tear in the septum should be closed by interrupted 
sutures introduced from the vaginal aspect. The suture 




Fig. 41. — Denudation. Sutures Fig. 42. — Laceration of the recto-vagi- 

introduced to close the laceration nal septum closed. The operation is com- 
of the recto-vaginal septum. pleted by the introduction of sutures as in 

Fig- 38. 

is passed through the vaginal mucous membrane at about 
an eighth of an inch from the edge of the wound, and 
emerges in the edge of the rectal mucous membrane. It 
should not pass through the rectal mucous membrane. 
After the sutures in the recto-vaginal septum have been 
shotted, the operator may proceed to repair the perineum 
and the sphincter ani muscle (Figs. 41, 42). 



INJURIES TO THE PERINEUM. 75 

There is a variety of perineal laceration (between the 
first slight median laceration and the second complete 
laceration through the sphincter ani) in which only the 
outer fibers of the sphincter muscle are injured. In this 
injury partial incontinence results. The woman may be 
able to control feces when the movements are hard, but 
loses control over liquid feces and flatus. 

There is no loss of support of the pelvic floor, and the 
indication for operation is the partial incontinence. The 
operation is performed in a way similar to that already 
described for complete laceration. The ends of the rup- 
tured fibers of the sphincter muscles are usually indicated 
by a slight depression on the overlying skin or mucous 
membrane. 

laceration in One or Both Vaginal Sulci. — In 
this form of injury the tear takes place not in the median 
line, but in the direction of the vaginal sulci or furrows. 
The left sulcus is usually the more deeply torn. 

In this form of laceration the sphincter ani muscle 
usually escapes injury; the tear is directed toward the 
ischio-rectal fossa, and the rectum and anus are pushed to 
one side. The structures of importance that are injured 
are the fascia, the levator ani muscle, the sphincter mus- 
cle of the vagina, and perhaps the transverse perineal 
muscle. All the supporting structures of the perineum and 
of the posterior vaginal wall are injured. If the lacera- 
tion be bilateral, complete loss of support of the perineum 
and the posterior vaginal wall results, and if the condi- 
tion be untreated, all the disastrous consequences of loss 
of support of the perineum occur — prolapse of the vagina, 
of the uterus, and of the other pelvic organs. 

It is unusual that this form of laceration is entirely 
limited to one sulcus, though one is usually more involved 
than the other. When the injury is limited to one side, 
the perineum is still supported by the muscles and fascia 
upon the other side, and the tendency to prolapse is not 
so marked. 

The nature of this injury may always be detected by 



76 A TEXT-BOOK OF DISEASES OF WOMEN. 

examination after labor. The anterior vaginal wall 
should be elevated by a retractor, and the posterior wall 
should be carefully examined. An external tear of the 
skin, generally in the median line, usually accompanies 
laceration in the sulci; that is, the lacerations in the sulci 
converge toward the fourchette. 

The immediate operation should always be performed. 
The torn sulci should be closed by sutures introduced on 
the posterior vaginal wall (Fig. 43), and the external tear 




Fig. 43. — Sutures introduced for the closure of a recent perineal laceration in 

the sulci. 



should be closed by sutures introduced as in the first form 
of injury to the perineum, already described. 

If this form of perineal injury is not repaired by the 
immediate operation, cicatrization takes place, and the 
tears in the mucous membrane and in the skin become 
healed. The fascia retracts, and the integrity of the sup- 
porting planes of fascia is destroyed. The torn muscles, 
the inner fibers of the levator ani and the sphincter vag- 
inae, also retract and cease to furnish any support to the 
perineum. In health these muscles embrace the lower 
portion of the posterior vaginal wall like a sling, draw- 



INJURIES TO THE PERINEUM. J 'J 

ing it toward the symphysis pubis; after laceration in the 
sulci the support of one or both of the arms of the sling 
is destroyed. 

The scars upon the mucous membrane and on the skin 
in time become faint, with difficulty perceptible. By 
elevating the anterior vaginal wall and closely inspecting 
the posterior wall immediately within the ostium vaginee 
we may detect a fine irregular white line running in the 
direction of the vaginal sulcus and dividing the normal 
transverse ridges and furrows of the vaginal mucous 
membrane. This is the only sign of former injury to 
the vaginal mucous membrane. The injury to the under- 
lying structures — the supporting structures of the peri- 
neum, the muscles and the fascia — is indicated by certain 
characteristic and unmistakable signs. These signs are 
best recognized after a careful study of the normal unin- 
jured perineum. 

If an uninjured woman be placed in the lithotomy 
position and the perineal region be carefully examined, 
we observe the following points: 

The anus is not prominent: it is drawn upward and 
forward ; the anal cleft is deep. 

The perineum, or the surface between the anus and the 
fourchette, is shallow; the distance from the anus to a 
fixed point like the external meatus is relatively short: 
this surface is more or less convex, showing muscular 
tonicity. 

If the labia are separated, it will be observed that the 
anterior and posterior vaginal walls are in close apposi- 
tion. If the woman is made to strain or to bear down, 
the vaginal walls appear to come into close contact; the 
perineum is pushed directly downward, aud becomes more 
prominent under the increased intra-abdominal pressure, 
but there is no tendency to eversion or rolling out of the 
vaginal walls. 

If the vulva is pricked with a needle, reflex muscular 
action is immediately observed: the anus is drawn still 
more upward and forward; the perineum is shortened; 



78 



A TEXT-BOOK OF DISEASES OF WOMEN. 



the ostium vaginae is closed more firmly by the draw- 
ing forward of the posterior margin of the opening. 
The test shows that the muscles supporting the perineum 
are intact. 

If the finger be introduced into the vagina and be 
pressed backward and outward in either vaginal sulcus, 
resisting structures are felt. There seems to be a band, 
perhaps half an inch in breadth, immediately within the 
ostium vaginae, that holds forward the perineum and the 
posterior vaginal wall and resists the pressure of the 
finger. 

Compare these characteristic features of the uninjured 
perineum with what we observe in a woman in whom 
there has been an untreated laceration of the perineum 
in the vaginal sulci. Here the supporting structures of 
the perineum have been destroyed. 






ABC 

Fig. 44. — Diagram showing the sling of muscle and fascia supporting the 
perineum and the posterior vaginal wall. In a the parts are intact; in B there 
has been a laceration in the left vaginal sulcus ; in c there has been a laceration 
in both sulci ; a suture has been introduced on the right side. 



The anal cleft is shallow. The anus is prominent; the 
surrounding structures present the appearance of relaxa- 
tion. The perineum is deep; the distance from the anus 
to the external meatus is longer; the anus has really 
dropped back. The skin-surface of the perineum is flat 
and relaxed. 

If the labia are separated, the anterior and posterior 
vaginal walls will not be found in close apposition. The 



INJURIES TO THE PERINEUM. 



79 



ostium vaginae is patulous and gaps open (Fig. 45). If 
the woman is made to bear down, the anterior and pos- 
terior vaginal walls are not pushed together; they are 
rolled out and protrude through the ostium vaginae. 

If the vulva is pricked with a needle, the woman draws 
herself away ; there is no reflex muscular action, closing 
the vagina and drawing up the anus. The muscles of 
the perineum have been destroyed. 

If the finger is introduced in the vagina and pressed 
backward and outward in 
either vaginal sulcus, the 
tissues are yielding and 
soft ; no supporting sling 
of muscle and fascia is 
felt. 

These phenomena have 
an' unmistakable mean- 
ing, and indicate clearly 
the loss of the support- 
ing structures of the pel- 
vic floor. 

The student should 
acquire familiarity with 
these tests by repeated 
experiments on injured 
and uninjured women. 
It will easily be under- 
stood that the same phe- 
nomena characterize the 
fourth form of injury to 
the perineum — the sub- 
cutaneous laceration. 

A perineum in this con- 
dition is often said to be 
relaxed. It is relaxed 
because the muscular and fascial supports have been 
destroyed. 

Treatment. — The treatment is directed to the restora- 




Fig. 45. — An old laceration of the 
perineum in both sulci. Rectocele. The 
mouth of the vagina is held open to show 
the appearance of the parts before opera- 
tion : a, apex of the rectocele. 



8o 



A TEXT-BOOK OF DISEASES OF WOMEN. 



tion of these supports. Each vaginal sulcus must be 
denuded, so that the condition existing in the recent 
injury (Fig. 43) is reproduced, and the sutures must be 
passed so that the retracted muscles and the fascia are 
brought back to their normal attachments. The best 
method of operating for this condition has been devised 
by Emmet. 

Emmet's Operation (Figs. 45-55). — When the labia 




Fig. 46. — The rectocele is seized 
with the tenaculum at a, and is drawn 
to the right, exposing the left vaginal 
sulcus, a, b, c, which must be denuded. 
The point b should be secured with a 
tenaculum before denuding. 



Fig. 47- 



-Method of denuding the 
sulcus. 



have been separated, it will be observed that there is a 
bulging or prominence of the lower portion of the poste- 
rior vaginal wall, which is called a rectocele. The most 



INJURIES TO THE PERINEUM. 



81 



prominent point or the apex of the rectocele should be 
held by a tenaculum or by a silk ligature passed imme- 
diately beneath the mucous membrane. 

This point should be such that it may without undue 
traction be drawn to either orifice of the vulvo-vaginal 
glands. 

If the apex of the rectocele is drawn to one side, there 




Fig. 48. — The left sulcus denuded 



Both sulci denuded. 



is formed on the other side a triangular area (Fig. 46, a, 
b, c). The base of this area (a, c) is at the ostium vaginae. 
The inner side (#, b) runs along the side of the rectocele. 
The outer side (£, c) runs along the lateral vaginal wall. 
The apex b is approximately the highest point of the 
tear in the sulcus. The angle c is immediately below 
the orifice of the vulvo-vaginal gland. The angle b is 
fixed by a tenaculum held by an assistant, and the tri- 



82 A TEXT-BOOK OF DISEASES OF WOMEN. 



angular area is denuded. The denuded area does not 
correspond exactly with the original tear in the sulcus, 
but the denudation exposes the sulcus, so that sutures 
may b*e passed in such a way as to include the muscles 
and fascia. The sulcus on the opposite side is then 
denuded in a similar manner, and the lower face of the 
rectocele is denuded. It is best to begin the denudation 
by seizing with tissue-forceps the mucous membrane of 




Fig. 50. — Introduction of the su- 
tures. The point of the emerging 
needle is held by the tenaculum. 



Fig. 5] 



-Sutures introduced in both 
sulci. 



the posterior vaginal wall at the ostium vaginae, at the 
junction of skin and mucous membrane, and to remove 
contiguous strips of tissue by cutting upward toward the 
apex of the vaginal sulcus (Fig. 47). 

In the denudation no skin is sacrificed. The denuda- 
tion is not carried below the line of junction of vaginal 
mucous membrane with skin. 



INJURIES TO THE PERINEUM. 



83 



Each sulcus is closed by sutures separately, as in the 
immediate operation. The first suture is passed across 
the upper angle b. 




FlG. 52. — Method of securing sutures 
with perforated shot. 



Fig. 53. — Both sulci are closed. 
The support of the perineum is re- 
stored. The posterior wall of the va- 
gina is brought forward. The rectocele 
is cured. 



The second suture is introduced about an eighth of an 
inch from the edge of the mucous membrane on the left 
vaginal wall, is passed backward, downward, and out- 
ward so as to grasp retracted muscular fibers, and is made 
to emerge at the bottom of the sulcus. It is then re- 
introduced and passed forward between the mucous mem- 
brane of the rectum and the denuded surface, and some- 
what upward, to emerge on the edge of the mucous 
membrane of the rectocele. A third and, if necessary, 



84 A TEXT-BOOK OF DISEASES OF WOMEN. 

a fourth suture are passed in a similar manner. Similar 
sutures are then passed to close the right-hand sulcus. 

The sutures thus far introduced are sufficient to close 
the sulci, and therefore to restore the supporting struc- 
tures of the perineum. The remaining sutures are 




Fig. 54. — Sutures for closing the super- 
ficial perineum and fourchette. The an- 
terior suture is called the " crown suture." 



Fig. 55. — Emmet's operation of 
perineorrhaphy completed. Com- 
pare this figure with that represent- 
ing the condition of the parts before 
operation (Fig. 45). 



merely to close the skin-perineum. The first of these 
sutures is called the crown suture. The needle is intro- 
duced on the cutaneous aspect of the perineum, at the 
anterior end of the lateral denudation. It passes out- 
side of the denuded area, and emerges within the de- 
nuded area, at the edge of the mucous membrane of the 
vaginal wall, immediately below the last suture of the 



INJURIES TO THE PERINEUM. 85 

sulcus. It is then passed so as to transfix trie rectocele 
beneath the mucous membrane, and across the lateral 
denudation on the other side. When this suture is shotted 
the fourchette is restored. A second suture behind the 
crown suture is usually necessary to complete the clos- 
ure of the skin-perineum. 

The sutures in the sulci are shotted first, then the ex- 
ternal sutures are shotted. 

The second and third varieties of perineal injury are 
sometimes found associated in women who have borne 
more than one child, the injuries having in all probability 
occurred at different labors. In such a case the sulci 
should be denuded and closed as already described, and 
then the skin-perineum and the sphincter ani should be 
repaired. 

Subcutaneous laceration of the Muscles and 
Fascia. — The fourth variety of injury to the perineum — 
subcutaneous laceration of the muscles and fascia — is not 
uncommon. The structures which compose the pelvic 
floor are of different degrees of elasticity, and sometimes 
the mucous membrane and skin at the vaginal outlet will 
stretch, and not rupture, before the advancing head of 
the child, while the underlying structures — the muscles 
and fascia — may give way. Therefore the injury is said 
to be a subcutaneous laceration. The sphincter ani is 
never involved in this form of injury. The injury always 
takes place in the direction of the vaginal sulci, and the 
supporting muscles of the pelvic floor and the planes of 
fascia are the structures which are torn. The disability 
is exactly the same as in the third variety of perineal 
tear, with the absence of laceration of mucous membrane 
and skin. 

It is not to be expected that this injury will be posi- 
tively recognized at the time of labor, and therefore the 
immediate operation cannot be applied to it. The condi- 
tion is often described as relaxation of the perineum. 
The disabilities following this injury, and the tests by 
which it may be recognized, are identical with those 



86 A TEXT-BOOK OF DISEASES OF WOMEN. 

already described under old lacerations in the sulci. 
The treatment is also the same. The vaginal sulci must 
be denuded as though the mucous membrane had in 
reality been torn, and the sutures must be introduced in 
such a way as to bring back the muscles and the fascia 
to the former attachments. 



CHAPTER VII. 



RESULTS OF LACERATION OF THE PERINEUM. 

Rectocele. — A rectocele (Fig. 56) is the tumor formed 
by the protrusion of the lower part of the posterior vag- 
inal wall into the vagina or 
through the ostium vaginae. 
The condition is due to a 
prolapse of the posterior 
vaginal wall, and is caused 
by the loss of the support 
of the perineum, usually 
the result of laceration at 
childbirth. Sometimes the 
mucous membrane of the 
vagina alone prolapses, the 
anterior wall of the rectum 
remaining in place. Usu- 
ally, however, the anterior 
rectal wall and the posterior 
vaginal wall protrude to- 
gether. If the rectocele 
is not so extensive as to 
protrude through the os- 
tium, the woman may be % 
unaware of its existence. In many cases, however, the 
prolapsing vaginal wall protrudes at the vulvar cleft when 
the woman is erect, or when she strains at stool or per- 
forms work requiring heavy lifting. The woman ofteii 
says that under such circumstances the "womb" pro- 
trudes. On account of the accompanying prolapse of the 
anterior rectal wall the passage of feces does not take 
place in the normal direction, but the fecal mass is forced 

87 




Fig. 56. — Rectocele and cystocele. 



88 



A TEXT-BOOK OF DISEASES OF WOMEN. 



into the pouch of the anterior wall of the rectum, and 
straining efforts push it forward into the vagina. The 
woman says she feels as though the passages were about 
to take place through the vagina. This discomfort is 
relieved by pressing the rectocele back with the finger 




Fig. 57. — Median sagittal section of the pelvis of a woman in whom there 
has been a laceration of the perineum in the sulci, with rectocele and cysto- 
cele. The vagina is no longer a closed slit. 



during defecation. Accumulation of feces in the rectal 
pouch may result in inflammation or ulceration. The 
condition is readily recognized by introducing a finger 
into the rectum, when it will be found to enter the 
rectocele. 

A rectocele is cured by Emmet's operation, which 
restores the support of the perineum and the posterior 
wall of the vagina. 

Cystocele. — A cystocele is a tumor formed by the pro- 



RESULTS OF LA CERA TION OF THE PERINEUM. 09 

trusion of the lower part of the anterior vaginal wall into 
the vagina or through the ostium (Fig. 56). The pro- 
lapse of the vaginal wall is accompanied by prolapse of 
the posterior wall of the bladder. A sound introduced 
into the bladder through the urethra will be found to 
enter the cystocele. This test, and the soft, reducible 
character of the cystocele tumor, enable us to diagnos- 
ticate between cystocele and cyst of the anterior vaginal 
wall. The condition is caused by a loss of the support 
of the anterior vaginal wall that is furnished by the pos- 
terior wall and the perineum. 

In a case of cystocele residual urine often remains in 
the pouch of the bladder- wall. In some cases the woman 
learns that, in order to empty the bladder, it is necessary 
for her to push the cystocele upward and forward at every 
act of micturition. The result of this inability to empty 
the bladder is decomposition of the urine and resulting 
cystitis. 

Many cases of so-called irritable bladder and chronic 
cystitis are caused primarily by laceration of the peri- 
neum, which produces cystocele or prolapse of the pos- 
terior wall of the bladder; and such cases can be cured 
only by curing the cystocele. 

A cystocele varies much in size. Every long-standing 
case of laceration of the perineum in the sulci presents 
a certain degree of prolapse of the anterior vaginal wall. 
The tumor may remain within the vagina and be rendered 
prominent only upon efforts at straining, or it may pro- 
trude through the vulva as a mass the size of a duck's 

egg- 

As a cystocele is caused by laceration of the perineum, 
it can be cured only by repair of this laceration. The 
most important part of the treatment, therefore, is peri- 
neorrhaphy, which should always be performed. Usually 
this operation is sufficient. If the anterior wall of the 
vagina is supported, the tissues will recover their tonicity 
and contract, and the tumor will disappear. 

In some cases, however, where the mucous membrane 



9 o 



A TEXT-BOOK OF DISEASES OF WOMEN. 




Fig. 58. — Oval denudation for cysto- 
cele : sutures introduced. 



of the anterior vaginal wall 
has become much stretched 
and redundant in the nor- 
mal-sized vagina, it is ad- 
visable, in addition to the 
perineorrhaphy, to perform 
a plastic operation on the an- 
terior wall in order to dimin- 
ish the area of the vaginal 
mucous membrane. Such 
an operation is called an- 
terior colporrhaphy. A va- 
riety of operations of this 
kind have been invented. 
The various forms are mod- 
ified according to the requirements of the case and the 
whims of the operator. In one form of operation an 
oval area is denuded (Fig. 58), and the edges are brought 
together by interrupted sutures 
passed beneath the whole de- 
nuded surface. 

As the transverse measure- 
ment of the vagina is greater 
in the upper than in the lower 
part, an operation by which a 
greater amount of the excess 
of tissue is taken in above 
than below is often desirable. 
Such an operation is repre- 
sented in Fig. 59. Two strips, 
about one-third to one-half 
inch in breadth, are denuded 
on each side of the anterior 
wall, extending from the posi- 
tion of the internal urinary meatus upward toward the 
lateral vaginal fornices. The length of these strips varies 
with the case, and depends upon the size of the upper 
portion of the vagina. It is often desirable to carry the 




Fig. 59. 



-Sims' operation for 
cystocele. 



RESUL TS OF L ACER A TION OF THE PERINEUM. 91 

denudation to the level of the external os. The denuded 
surfaces are brought into apposition by interrupted sutures. 
By this operation the whole caliber of the vagina is nar- 
rowed from above downward. The degree of divergence 
of the denuded strips may be determined by seizing por- 
tions of tissue with tenacula upon each side and bringing 
them together, thus determining the amount of tension 
which will be put upon the sutures. 

In Dudley's operation the denudation is made and the 
sutures are introduced as shown in Fig. 60. The advan- 




Fig. 60. — Dudley's operation for cystocele (Ash ton, modified from Dudley V 

tage claimed for this operation is that by it the upper end 
of the vaginal wall is attached to the bases of the broad 
ligaments. 

The operation of anterior colporrhaphy must always be 
accompanied by perineorrhaphy. The anterior operation 
should be performed first. The woman should be placed 
in the Sims or the dorsal position. 

Enterocele. — Enterocele, or entero-vaginal hernia, is 
a rare condition. It consists of a hernia, or prolapse, of 



92 A TEXT-BOOK OF DISEASES OF WOMEM. 

the intestine into the vaginal canal. Two forms of the 
disease have been described — the anterior and the poste- 
rior. The latter is the more common. In the posterior 
variety one or more loops of the intestine, or the omen- 
tum, reach the bottom of Douglas's pouch and push 
the posterior vaginal wall forward, so that it encroaches 
upon the vaginal canal and in some cases protrudes from 
the ostium vaginae. 

The causes of this disease are not known. It is prob- 
ably favored by loss of support of the perineum and the 
vaginal walls. An unusually deep pouch of Douglas 
would predispose a woman to this condition. 

In the anterior form of the disease the hernia occurs at 
the bottom of the vesico-uterine pouch. 

The posterior enterocele may be distinguished from 
rectocele by introducing a finger into the rectum and 
one into the vagina, when the prolapsed intestine or 
omentum may be felt between the anterior rectal wall 
and the posterior vaginal wall. The condition may be 
distinguished from vaginal cyst by percussion and pal- 
pation. 

In the treatment of enterocele any existing injury to 
the perineum should be repaired, and the vagina should 
be narrowed by one of the plastic operations already de- 
scribed. Great care should be taken not to injure with 
the needle the intestine underlying the vaginal wall. 

Subinvolution of the Vagina. — It should be remem- 
bered, in connection with the subject of prolapse of the 
vaginal walls as a result of loss of the perineal support, 
that there is always present, also, a condition of subin- 
volution of the vagina. During pregnancy all the ele- 
ments of the vagina undergo a physiological hypertrophy 
analogous to that which occurs in the uterus. After 
labor the vagina normally undergoes certain changes by 
which it is again approximately restored to the dimen- 
sions, shape, etc. that existed before pregnancy. This 
change is called the involution of the vagina. Anything 
that arrests this process of involution produces a state of 



RESULTS OF LACERATION OF THE PERINEUM. 93 

subinvolution of the vagina ; this structure is then found 
much larger and more relaxed than normal, and a cer- 
tain hypertrophy of all the elements of the vaginal walls 
persists. Such subinvolution of the vagina is caused by 
the various pelvic lacerations, which, by causing loss of 
support to the pelvic vessels, result in a state of passive 
congestion. 

These redundant vaginal structures usually disappear 
and contraction takes place after the operation of perin- 
eorrhaphy. In some cases, however, when the vagina is 
very much larger and more relaxed than normal, it is 
advisable to remove some of the excess of tissue by a 
plastic operation on the anterior wall similar to that 
described for the relief of cystocele. 



CHAPTER VIII. 

THE POSITION OF THE UTERUS AND THE MECH- 
ANISM OF ITS SUPPORT. 

The uterus normally lies with its anterior surface in 
contact with the posterior aspect of the bladder, no in- 
testines intervening. The absolute and relative posi- 
tions of the uterus depend upon the degree of disten- 




Fig. 61. — Normal range of position of the uterus, depending upon the distention 
of the bladder. 



tion of the bladder and the position of the woman. The 
uterus is pushed backward and the fundus is turned up- 
ward by distention of the bladder. When the woman is 
erect the uterus lies at a slightly lower level than when 
the woman is on her back, and the intra-abdominal pres- 

94 



POSITION OF THE UTERUS. 



95 



sure acting upon the posterior surface of the fundus turns 
the uterus more forward, so that the fundus lies nearer 
the symphysis pubis. Fig. 61 shows about the normal 
range of position. 

It may be said that in the normal woman the long axis 
of the uterus is approximately perpendicular to the long 
axis of the vagina (Fig. 62). 




Fig. 62. — Median sagittal section of the normal female pelvis. 

The uterus does not surmount the vagina with the axes 
of the two structures in the same line, as is shown in some 
anatomical plates. 

The cervix looks backward toward the coccyx, from 
the tip of which it is situated 0.6 to 1.2 inches. 

The uterus is maintained in position by a variety oi 
factors. The ligaments, which have been described, are 
eight in number — broad ligaments, round ligaments, 
utero-sacral and utero-vesical ligaments. 



96 A TEXT-BOOK OF DISEASES OF WOMEN. 

With the exception of the round ligaments, which are 
muscular structures, the uterine ligaments are formed by 
peritoneal folds, including connective tissue, blood-ves- 
sels, lymphatics, and a small amount of unstriped muscle. 

When the woman is erect the insertions and origins of 
the various uterine ligaments lie in the same horizontal 
plane. The insertion of no ligament is higher than its 
origin in the uterus; therefore these ligaments do not act 
as suspensory ligaments when the uterus is in its normal 
position. The truth of this fact is repeatedly demon- 
strated at operations. If the cervix be caught with a 
tenaculum when the woman is on her back, the uterus 
may, with but very little force, be drawn downward 
toward the ostium vaginae to the extent of one or two 
inches; and similarly, by a slight digital pressure on the 
cervix, the uterus may be pushed upward from one to 
two inches above its normal position. 

The ligaments of the uterus act as guys. They steady 
it, and prevent too great lateral and fore-and-aft move- 
ment; they do not, when the uterus is in its normal posi- 
tion or at its normal level, sustain it against the force of 
gravity. When, however, the uterus, for any reason, 
falls an inch or more below its normal level, the uterine 
ligaments become suspensory in character. 

In the normal woman the vagina is always closed. As 
has already been said, it is a slit in the pelvic floor, val- 
vular in character; consequently the abdominal and pelvic 
viscera may be considered to be contained in a closed 
vessel, in woman as well as in man. The uterus floats in 
this closed vessel at a level which is consistent with its 
own specific gravity. If, for any reason, the specific 
gravity of the uterus were increased, it would sink below 
the level at which it is normally situated. 

Since, normally, there is no tendency in the uterus to 
change its position, the pressure upon it must be equal in 
all directions. The subject may perhaps be better under- 
stood by referring to a few simple facts in hydrostatics. 
If a fluid contained in a closed vessel be in a condition 



POSITION OF THE UTERUS. 



97 



of equilibrium so that its various particles are at rest, 
then the pressure upon any particle is equal and opposite 
in all directions (Fig. 63); otherwise the particles would 

















' 




X 




'/ 


\" 








\ 


f 














X 








V t \ 


/ A V V V 



Fig. 63. — Vessel containing fluid in equilibrium. The arrows indicate the 
direction of the pressure at various points. 

not be in equilibrium, but would move. The bottom of 
such a vessel, however, is not, like the particles of the 
fluid, surrounded on all sides by the fluid, but above it is 
the fluid, and below it is the atmospheric air. Any point 
upon the bottom of the vessel is subjected to a downward 
pressure equal to the weight of the column of fluid above 
the point; this downward pressure is resisted by the 
strength of the material composing the vessel. If this 
material be yielding or elastic in character, the pressure 
above will make the bottom protrude to a certain extent. 
A particle within the fluid (like X immediately above the 
bottom of the vessel) will be subjected to a downward 
pressure equal to the weight of the column of fluid above 
it; but this pressure will be counterbalanced not by any 
strength in the particle, but by a counter-force acting 
from below equal and opposite to that acting from above. 
A similar state of things exists in the female pelvis. 
The uterus floats at a certain level, and the intra-abdom- 
inal pressure acting from above is counterbalanced by an 
7 



98 A TEXT-BOOK OF DISEASES OF WOMEN. 

equal force acting from below, while the floor or bottom 
of this vessel (part of which is the perineum) is subjected 
to a force from above equal to the intra-abdominal pres- 
sure, and this force is opposed only by the strength of the 
perineum (see Fig. 64). 




FlG. 64. — Diagram representing the directions of the intra-abdominal pressure 
upon the uterus in the uninjured woman. 

If the vagina were an open tube admitting air, so that 
the uterus above was in contact with the contents of the 
pelvic vessel and below with atmospheric air, then the 
condition of things would be altered. In this case the 
uterus would in reality become part of the floor of the 
vessel, and would be subjected to a pressure from above 
equal to the intra-abdominal pressure, and to this pres- 
sure would be opposed only the strength of the uterus 
and its attachments. Such a state of things occurs when 
the perineum is torn and the vagina becomes a patulous 
open canal, and not a closed slit. Therefore when the 
opening of the vagina is torn and air constantly enters 
the vaginal canal, the normal hydrostatic equilibrium of 
the pelvic contents is destroyed, the resultant of the 
forces acting upon the uterus is downward, and the 
organ has a tendency to fall or to prolapse (Fig. 65). 

The normal perineum and vagina do not sustain the 



POSITION OF THE UTERUS. 



99 



uterus by furnishing a mechanical support from below, 
any more than the bottom of a vessel sustains any single 
particle of fluid floating in it. 

When the uterus tends to fall down or to prolapse, its 
progress is opposed at a certain level by its various attach- 




Fig. 65. — Diagram representing the direction of the intra-abdominal pressure in 
the woman with a laceration of the perineum. 

ments. The ligaments become suspensory in character as 
soon as their uterine attachments are below their pelvic 
attachments. The cellular tissue, fat, blood-vessels, etc. 
connected with the uterus restrain its downward motion. 
And, finally, this motion is restrained by what has been 
called the " retentive power of the abdomen," which is 
merely the atmospheric pressure acting from below on 
the contents of a vessel the top and sides of which are 
closed. 

Refer again to a simple physical example : If a glass 
tube be filled with water, a finger placed over one end, 
and the tube inverted, the water will not run out: it is 
sustained by atmospheric pressure acting from below. 
If the finger be removed, atmospheric pressure also acts 
from above, and the water will fall. If a hole be made 
in the side of the tube, atmospheric pressure will act 
through it, and the water below the hole will fall. 



IOO A TEXT-BOOK OF DISEASES OF WOMEN. 

In order that the column of water be sustained, the 
sides of the tube must be rigid or unyielding. If the 
sides of the tube yielded slightly to atmospheric pres- 
sure, they would sink in and a certain amount of water 
would escape. 

The abdominal and pelvic cavities in the erect woman 
may be considered as a tube filled with fluid contents. 
The top of the tube is closed by the diaphragm ; the sides 
are the more or less rigid abdominal walls and the back; 
the floor is the perineum. When the floor is destroyed a 
hole is made in the bottom of the tube : the contents tend 
to fall, but the fall is resisted by atmospheric pressure 
acting from below. If the diaphragm and the parietes 
were rigid as glass, there would be no prolapse, any more 
than there is prolapse of the water in the glass tube. If 
the parietes yield somewhat, the amount of fall or pro- 
lapse is proportional. Thus the retentive power of the 
abdomen is dependent upon the strength or rigidity of 
the abdominal walls. 



CHAPTER IX. 
PROLAPSE OF THE UTERUS. 

Prolapse of the uterus means a falling of that organ 
below its normal level. The condition is popularly 
spoken of as "falling of the womb." There are an 
infinite number of degrees of prolapse of the uterus, 
between the slightest descent on the one hand and 
complete protrusion of the organ from the body on the 
other hand. The term "complete prolapse" should 
properly be applied to the entire protrusion of the 
uterus outside of the vulva. This condition, however, 
is most unusual. The term is generally used to desig- 
nate those cases in which the cervix alone, or the cervix 
and part of the body of the uterus, protrude from the 
vulva (Fig. 66). In any case of prolapse of the uterus it 
is best to describe in detail the extent of the prolapse and 
the other conditions present. Thus, some of the various 
kinds of prolapse may be described as follows: "Pro- 
lapse of the uterus, the cervix resting on the pelvic 
floor;" "prolapse of the uterus, the cervix presenting at 
the vulvar cleft;" "prolapse of the uterus, the cervix 
protruding about two inches from the ostium vaginae, 
with elongation of the supra-vaginal cervix," etc. 

Injury to the pelvic floor that allows air to enter the 
vagina destroys the normal equilibrium of the pelvic 
contents and exposes the uterus to a direct abdominal 
pressure from above, which is not counterbalanced by an 
equal force from below, but is opposed by the strength 
of the uterus and its attachments and the retentive power 
of the abdomen. Most cases of prolapse occur in women 
in whom the perineum has been injured at childbirth. 

There are a number of predisposing causes of uterine 

101 



102 A TEXT-BOOK OF DISEASES OF WOMEN. 

prolapse that permit the descent to progress after the 
uterus has begun to fall — namely : Relaxation of the 
uterine ligaments that results from too frequent partu- 
rition, from old age, or from tissue-weakness which is 
part of a general condition, the uterine ligaments sharing 
the general feebleness of the other tissues and structures 
of the body; relaxation, loss of rigidity, or muscular 




Fig. 66. — Prolapse of the uterus, the cervix protruding from the vulva. There 
is a bilateral laceration of the cervix. 



weakness of the abdominal parietes, which diminishes 
the retentive power of the abdomen; diminution of the 
cellular tissue and the fat of the pelvis, such as occurs in 
wasting disease or in old age. Anything that suddenly 
increases the intra-abdominal pressure, such as lifting a 
heavy weight, may cause acute prolapse of the uterus. 
In some cases the uterus has suddenly protruded from the 
bodv as a result of heavv lifting. In cases of this cha- 



PROLAPSE OF THE UTERUS. 103 

racter it is probable that the muscular supports of the 
perineum have been weakened from some cause, or that 
the sudden increase of abdominal pressure drives the 
uterus downward before the perineal muscles have time 
to contract and close the vaginal outlet. In such cases 
there is also present rupture of the uterine ligaments. 
Constant violent coughing has produced uterine prolapse 
in a similar way. 

Extreme uterine prolapse sometimes occurs in a nullip- 
arous woman in whom the perineal supports are natu- 
rally weak. In such women there exists a condition of 
relaxation identical in results with subcutaneous lacera- 
tion of the perineum. 

Anything that increases the specific gravity of the 
uterus will make it sink somewhat lower in the pelvis. 
Subinvolution, congestion from inflammation, or retro- 
flexion may do this. In such cases, however, the pro- 
lapse never becomes extreme, rarely extending beyond a 
slight sinking of the uterus. 

In most cases uterine prolapse takes place slowly. 
Sometimes many years are necessary for the develop- 
ment of complete prolapse. The equilibrium of the 
pelvic contents is destroyed by one of the causes already 
mentioned. The uterus falls through a certain distance 
before the uterine ligaments become suspensory. *Then, 
however, its further descent is impeded. 

If the original cause continues to act, the uterine liga- 
ments become stretched and the descent of the uterus 
gradually progresses, impeded to a varying degree also 
by the retentive power of the abdomen and the cellular 
tissue and other pelvic attachments. 

x\s the uterus descends, the vaginal walls attached at 
the cervix are dragged down with it, so that when the 
prolapse becomes complete the vagina is turned inside 
out (Fig. 67). 

When the perineum has been injured so that the lower 
portion of the vagina loses its support and the equilib- 
rium of the pelvic contents is destroyed, two distinct 



104 A TEXT-BOOK OF DISEASES OF WOMEN. 

phenomena occur : The uterus falls as already described, 
and at the same time the lower part of the vagina begins 
to fall, so that there appear a prolapse of the anterior vag- 
inal wall, or a cystocele, and a prolapse of the posterior 
wall, or a rectocele. The condition finally produced will 




Fig. 67. — Complete prolapse of the uterus. 



depend upon which prolapse takes place the more rap- 
idly — that of the vagina or that of the uterus. 

If the prolapse of the lower vagina progresses faster 
than that of the uterus, then the vagina will begin to 
drag upon the cervix, to which it is attached, and under 
these circumstances the uterus will be subjected to two 
downward forces — intra-abdominal pressure from above, 
and traction of the vaginal walls acting from below. 

As the traction is exerted upon the lower part of the 
cervix, and the body of the uterus is sustained by the 
uterine ligaments, which resist the downward traction, 
the isthmus, or point of junction of the body and cervix, 
is dragged out or stretched, so* that in some cases a very 



PROLAPSE OF THE UTERUS. 



105 



marked elongation of the supra-vaginal cervix, or the 
part of the cervix above the vaginal junction, appears. 
This elongation is sometimes so great that the length of 
the uterine cavity from external os to fundus measures 
six or eight inches. Such elongation of the cervix is 
usually found to a greater or less degree in every case of 
marked prolapse of the uterus caused by injury to the 




Fig. 68. — Prolapse of the vagina and the vaginal cervix, with great elongation 
of the supra-vaginal cervix. 



perineum. Such a condition should be described as pro- 
lapse of the uterus with elongation of the supra-vaginal 
cervix (Fig. 68). In many cases the prolapse of the va- 
gina and the elongation of the cervix are the most marked 
features, the body of the uterus falling but slightly below 
its normal level. The cervix will be found protruding 
some distance from the vulva; the vagina will be found 



106 A TEXT-BOOK OF DISEASES OF WOMEN. 

turned inside out; while the fundus may be felt approx- 
imately at its normal level in the pelvis, and the present- 
ing cervix and the body of the uterus are connected by 
a round, cord-like structure about the size of the little 
finger, which is the stretched, attenuated supra-vaginal 
cervix. 

As a result of the traction upon the cervix the blood- 
flow from the infra-vaginal cervix is impeded, and passive 




Fig. 69. — Prolapse of the vagina and cervix, with elongation of the supra-vagi- 
nal cervix. 

congestion results in hypertrophy. This hypertrophy is 
increased by irritation of the infra-vaginal cervix from 
friction against the clothing and from urine, etc. In 
such cases the presenting cervix becomes much larger 
than normal, sometimes measuring two or two and a 
half inches in diameter. 

It will be seen that very pronounced structural changes 
are present in old cases of prolapse of the uterus. The 
uterine ligaments and the pelvic attachments become so 
stretched and atrophied that they can never become func- 
tionally useful again. The normal shape and size of the 



PROLAPSE OF THE UTERUS. 



107 



uterus become very much changed from elongation of 
the supra-vaginal cervix and hypertrophy of the infra- 
vaginal cervix. The vaginal canal becomes patulous 
and stretched several times beyond its normal dimen- 




Fig. 70. — Prolapse of the vagina and the vaginal cervix, with elongation of the 
supra-vaginal cervix. Extensive ulceration. 



sions, and the delicate mucous membrane, from exposure, 
becomes tough and cutaneous in character. The large 
protruding mass of uterus and inverted vagina stretches 
the genital outlet far beyond its normal dimensions, and 
the muscular supports that may have remained after the 
original perineal injury undergo atrophy from pressure. 

Accompanying the prolapse of the uterus is usually 
prolapse of the bladder and of the anterior wall of the 
rectum, producing a condition already described under 
Cystocele and Rectocele. 

Women who do hard manual labor are those who suffer 
with the most marked forms of uterine prolapse. The 
form of prolapse accompanied by elongation oi the supra- 
vaginal cervix is usuallv characteristic of the hard-work- 



108 A TEXT-BOOK OF DISEASES OF WOMEN. 

ing woman. Such prolapse of the uterus is common 
among the Western Indian women, who return imme- 
diately after delivery to hard labor and horseback-riding. 
Many cases of prolapse would be avoided, even though 
there might be serious perineal injury, if women remained 
in bed a sufficient time after delivery. By rising too early 
prolapse is favored, for a variety of reasons. The uterus 




Fig. 



70, A. — Elongation of supravaginal cervix (St. Bartholomew's Hospital 
Museum). 



is large and heavy; the uterine ligaments are elongated, 
and the abdominal walls are weak ; consequently the 
retentive power of the abdomen is poor; the vagina is 
flabby and much larger than normal; the genital outlet 
has not contracted, and the muscular and fascial supports 
which may not have been torn are stretched and relaxed. 
The subjective symptoms of prolapse vary greatly and 
are not characteristic. A woman in whom the uterus has 



PROLAPSE OF THE UTERUS. 109 

descended but slightly below the normal level may suffer 
so much with backache, weakness of the legs, and a feel- 
ing of pelvic weight, or "bearing down," that her life 
will be rendered useless; while, on the other hand, a 
woman with complete prolapse of the uterus may suffer 
no inconvenience except from the presence of the pro- 
truding mass. In fact, the lesser degrees of prolapse seem 
to cause more suffering than the extreme degrees. 

The first subjective symptoms of injury to the supports 
of the pelvic floor that appear when the woman leaves 
her bed are those referable to beginning prolapse of the 
uterus. Backache is the most common symptom, and 
occurs here as in almost every other disease of the uterus. 
The pain, a dull ache, is situated in the upper part of 
the sacrum. It is increased by standing, by walking, or 
by manual labor. It often disappears entirely when the 
woman lies down and the intra-abdominal pressure is 
removed from the uterus. Headache situated in the 
occipital region or the vertex is also usually present, and 
varies in severity with the severity of the backache. 

Pain extending down the posterior aspect of the thighs, 
and a dragging feeling of loss of support in the pelvis, 
may also be present. The rectal and bladder symptoms 
occur later, when rectocele and cystocele appear. 

There is often very marked general physical weakness, 
much of which may be referred directly to the loss of the 
muscular support of the perineum. Almost every effort 
that the woman makes is accompanied by increase of 
intra-abdominal pressure, and she feels keenly the loss 
of the accustomed perineal support which normally 
resists any increased abdominal pressure. In the sound 
woman the perineal muscles contract and the vagina is 
more tightly closed to meet the increased pressure inci- 
dent to a muscular effort. In the injured woman the 
vagina is open and the pressure is resisted by weak 
vaginal walls and uterine supports. She feels that her 
point of resistance is gone. The best proof of the pro- 
found effect of injury to the perineum upon the general 
strength of a woman is given by the operation of peri- 



no A TEXT-BOOK OF DISEASES OF WOMEN. 

neorrhaphy. The repair of this apparently slight lesion 
restores the woman to her former strength. 

The diagnosis of prolapse of the uterus is readily 
made by examination. In the extreme cases the cervix 
and the greater part of the body of the uterus are found 
outside the vulva. In less marked cases the cervix 
is seen presenting at the vaginal orifice as soon as the 
labia are separated. In other cases the cervix is felt by 
the vaginal finger resting on the pelvic floor. It should 
be remembered that every case of prolapse is greater 
when the woman is standing than when she is being 
examined upon her back. Sometimes the cervix will 
present at the vulva, where it may be felt when the 
woman is erect; but when she lies down and intra- 
abdominal pressure is removed, it retreats beyond inspec- 
tion except through the speculum. In order to determine 
the full extent of prolapse, therefore, when the woman is 
examined on her back she should be directed to strain or 
bear down, when much more marked descent of the 
uterus and vaginal walls will become apparent. 

The lesser degrees of prolapse, in which the cervix has 
not yet fallen enough to rest on the pelvic floor, are more 
difficult to recognize by bimanual examination. It will 
be found that the upward range of motion of the uterus 
is greater than normal, and vaginal examination when 
the woman is erect will make the condition more 
apparent. 

Extreme prolapse of the uterus, in which we find pro- 
truding from the vulva a pear-shaped tumor at the apex 
of which is the opening of the cervical canal, should not 
be mistaken for any other condition. Inversion of the 
uterus and a uterine polyp resemble it only in shape, and 
in no other particular. If there is any doubt, it may be 
dispelled by placing the woman in the knee-chest posi- 
tion, when the prolapse may readily be reduced and the 
normal anatomical relations restored. 

Treatment. — As prolapse of the uterus is usually caused 
by injury to the pelvic floor, treatment should be directed 
in the first place to the restoration of the perineum. 



PROLAPSE OF THE UTERUS. ill 

In slight cases of prolapse that are seen early, restora- 
tion of the perineum by Emmet's operation is sufficient 
for cure. 

In cases of long duration, however, we have to deal 
with a variety of secondary conditions. These are as 
follows : Hypertrophy of the uterus from subinvolution 
or congestion; elongation of the cervix ; hypertrophy of 
the cervix; elongation of the uterine ligaments; stretch- 
ing of the vagina; stretching of the genital outlet; and 
atrophy of all the structures of the perineum from pres- 
sure. The atrophic changes give the most difficulty. 
The prognosis, therefore, depends upon the duration of 
the case. 

In cases of prolapse in which the cervix has reached or 
has passed the ostium vaginae, rest in bed in the recum- 
bent position should always be prescribed for two to four 
weeks before any operative procedure. The woman 
should be placed in the knee-chest position and the pro- 
lapse of the uterus and vagina should be reduced. Re- 
duction of this kind should be practised as often as the 
prolapse returns — as, for instance, after straining at stool. 
It may be performed by the woman herself or by the 
nurse. It is well for the woman to asssume the knee- 
chest position three or four times a day, for five to 
fifteen minutes at a time. One or two hot vaginal 
douches of a gallon of i : 4000 bichloride solution 
should be administered daily. The intestinal contents 
should be kept soft by laxatives. As a result of such 
preparatory treatment the uterus will diminish very much 
in size, and the vagina and the vaginal outlet will con- 
tract, so that at the time of operating the amount of tissue 
to be removed may be more accurately determined. The 
diminution in the length of an elongated cervix as a 
result of rest is most striking, and demonstrates the truth 
of the explanation of the etiology of this condition that 
has already been given. A uterine canal that measures 
five or six inches in length may be reduced to three or 
four inches after traction on the cervix has been removed 
by rest in bed. 



112 A TEXT-BOOK OF DISEASES OF WOMEN. 

Ulceration of the cervix, which is often present as a 
result of friction from exposure, readily yields to this 
treatment of rest and douches. 

From the considerations already referred to it will 
be seen that the operative treatment of any case of uter- 
ine prolapse varies according to the special conditions 
present. 

Perineorrhaphy is always necessary. Emmet's opera- 
tion is usually the best one. The denudation in the 
lateral vaginal sulci should be extended well up the pos- 
terior vaginal wall, in order to diminish the caliber of 
the overstretched vagina. One of the operations already 
described should also be performed for the cure of the 
cystocele and to diminish the area of the anterior vag- 
inal wall. The best of these operations are Sims' and 
Dudley's (Figs. 59 and 60). After all plastic operations 
for the cure of prolapse the woman should be kept in bed 
for three or four weeks — the longer the better — so that 
the perineal and vaginal structures and the ligaments of 
the uterus may contract and regain strength. 

In some cases of long standing it is impossible, by 
operation, to restore the integrity of the pelvic floor, and 
to restore the shape, size, and direction of the vaginal 
canal so that the normal equilibrium of the pelvic con- 
tents will be re-established. In such cases operators have 
attempted to build a direct mechanical support for the 
uterus. 

Le Fort's operation is an ingenious method of attain- 
ing this object. The uterus should be replaced, and a 
longitudinal strip of tissue, about one-half to one inch in 
breadth and two to two and a half inches in length, 
should be denuded on the anterior vaginal wall, extend- 
ing from a point near the vulva, where the two vaginal 
walls are in contact when the uterus is in place, up to- 
ward the cervix. A similar strip should be denuded on 
the posterior wall. These two denuded areas should be 
brought into apposition by interrupted sutures passed 
transversely. Perineorrhaphy should also be performed. 

In those cases in which the vagina and the vaginal 



PROLAPSE OF THE UTERUS. 



"3 



outlet have become very much stretched by the protrud- 
ing mass of prolapsed structures, Emmet's operation 
seems to be insufficient. In such cases the following 
operation is useful. This consists in denuding a tri- 
angular area on the posterior vaginal wall (Fig. 77), 
the apex of the denudation being immediately below the 
cervix, and the base at the ostium vaginae. The denuda- 




FlG. 71. — Prolapse of the vagina and of the infra-vaginal cervix. The 
sound showed the internal uterine length to be 5^ inches. An erosion ap- 
pears on the posterior margin of the os uteri. 

tion should extend well on to the lateral vaginal walls. 
The denuded area is then closed by sutures passed trans- 
versely. 

Judgment, derived from experience, is necessary in 
choosing and performing the various plastic operations 
for prolapse of the uterus. 

In every case of prolapse a certain degree of retrover- 
sion of the uterus is present. In fact, the uterus could 
not escape from the vagina unless the fundus were turned 
somewhat backward. The operation ot ventro-iixation 
of the uterus is therefore a useful adjunct in some eases 



H4 A TEXT-BOOK OF DISEASES OF WOMEN. 

A B 




Fig. 72. — Amputation of the hypertrophied cervix: A. The cervix has been split laterally. 
B. The posterior lip is being amputated. 




Fig. 73. — The posterior lip has been amputated. 



PROLAPSE OF THE UTERUS. 

A B 



JI 5 




Fig. 74. — A. Both lips have been amputated and the sutures have been introduced. B. The 
sutures have been secured by the perforated shot. 




Fig. 75.— A. The anterior vaginal wall is pushed backward by the staff, while on each side 
of the median line portions of mucous membrane are grasped by tenacula and brought to- 
gether in order to determine the position of the strips to be denuded. B. Denudation on the 
anterior vaginal wall (Sims' operation). 



Ii6 A TEXT-BOOK OF DISEASES OF WOMEN. 

A B • 




Fig. 76. — A. The suiures have been introduced. The prol.ipsed vagina and cervix have 
been reduced. The cystocele is pushed upward by the staff, so that the denuded strips may 
be brought into apposition. B. The sutures are secured. The cystocele has disappeared. 
The area of the anterior vaginal wall and the caliber of the vagina have been much di- 
minished. 

A B 




Fig. 77. — A. A point on the median line of the posterior vaginal wall, about an inch below 
the cervix, has been seized by the tenaculum. This marks the apex of a triangle the base 
of which is at the ostium vaginae and the sides of which are on the lateral vaginal walls. B. 
The triangle has been denuded. The sutures have been introduced. 



PROLAPSE OF THE UTERUS. 



117 



of uterine prolapse. The operation is not intended to 
furnish a mechanical support to the uterus, but only to 
keep it in a position of anteversion, so that it will less 
readily escape through the vaginal canal. The plastic 
operations and the ventro-suspension may all be done at 
the same sitting. 

Whenever there is hypertrophy of the infra-vaginal 
cervix, this structure should be amputated in addition to 
the other operations. 




FlG. 78. — The sutures in the posterior vaginal wall have been secured. The 
Caliber of the vagina has been very much diminished. A strong sling or band 
of tissue has been formed immediately above the ostium vaginae, which sup- 
ports the lower portion of the posterior vaginal wall. The operation is com- 
pleted. 



In those very rare cases of incurable prolapse that 
have resisted all conservative treatment the operation for 
the removal of the uterus may be considered. The writer 
has never resorted to it. The operation consists in supra- 
vaginal hysterectomy followed by fixation of the cervical 
stump by sutures to the abdominal wall. 

This operation, however, should not be proposed has- 



n8 A TEXT-BOOK OF DISEASES OF WOMEN. 

til)'. The surgeon should not become discouraged by one 
or even two failures of the more conservative methods of 
treatment. Though the first plastic operation may fail 
to retain the uterus inside the body, yet something is al- 
ways accomplished by it, and when supplemented by a 
second or a third operation, cure will often result. 

The operative procedures required in a case of pro- 
lapse of the vagina and of the infra-vaginal cervix, with 
hypertrophy of the infra-vaginal cervix and elongation 
of the supra-vaginal cervix, are illustrated in Figs. 71-78. 
The condition represented in Fig. 71 is that which is 
commonly spoken of as "prolapse of the uterus." It is 
the usual form of prolapse. It may be cured in the very 
great majority of cases by the operations which are here 
depicted. 

A great number of mechanical devices have been in- 
troduced for the relief of prolapse of the uterus. Every 
vaginal pessary has been used for this condition. None 
of these implements cure the disease. All of them, if 
used continuously, produce ulceration of the vagina and 
of the cervix from pressure, and must be abandoned until 
such lesions heal. In those cases of prolapse in which pes- 
saries remain in the vagina and support the uterus, with- 
out producing ulceration, operation would effect a cure. 

Mechanical supports of this kind are only indicated in 
women in whom operation is contraindicated on account 

of old age or for some other rea- 
son. Perhaps the best instru- 
ment for supporting the uterus 
in such cases is Braun's colpeu- 
rynter (Fig. 79). The uterus 
should be reduced, and the col- 
Fig. 79.— Braun's coipeurynter. peurynter, well greased and con- 
taining about an ounce of water, 
should be introduced in the vagina and then distended 
with air. This instrument takes its support evenly from 
all parts of the vaginal outlet, and is therefore less apt to 
produce ulceration from pressure than the various pessa- 
ries. It should be removed at night. 




CHAPTER X. 
ANTEFLEXION OF THE UTERUS. 

As has already been said, the uterus normally lies with 
its anterior surface in contact with the posterior surface 
of the bladder, and with its long axis approximately per- 
pendicular to the long axis of the vagina. The forward 
inclination of the uterus varies with the degree of dis- 
tention of the bladder; it is greatest when the bladder is 
collapsed. 

In the normal woman the long axis of the body of the 
uterus is inclined forward at an obtuse angle with the 
long axis of the cervix. In other words, the uterus is 
normally anteflexed. This angle is subject to rather wide 
variations within the limits of health. It is greater in 
the multiparous than in the nulliparous woman. It varies 
with the distention of the bladder, the position of the 
woman, and the intensity of intra-abdominal pressure. 
The axis of the uterus when removed from the body is 
usually straight. The anteflexion found in the organ 
when in situ in the living woman rarely persists. The 
normal or physiological anteflexion is maintained during 
life by the utero-sacral ligaments, which hold the cervix 
back, and the intra-abdominal pressure, which, acting 
upon the posterior aspect of the fundus, pushes the body 
of the uterus forward. 

In the fetus and in early infancy the cervix is rela- 
tively much more developed than the body of the uterus, 
and there is a very marked angle of flexion between 
them. 

Anteflexion of the uterus becomes pathological when 

119 



120 a TEXT-BOOK OF DISEASES OF WOMEN. 

the bend in the cervical canal is sufficient to impede the 
escape of menstrual blood or other uterine discharges. 

Obstruction of this kind depends upon two factors — 
the degree of the flexion, and the rigidity of the uterus, 
which diminishes the mobility that normally exists at 
the angle of flexion. 

No matter how sharp the angle of flexion, it should 
not be considered a pathological condition unless obstruc- 
tion in the cervical canal is present — unless the woman 
presents the symptoms of dysmenorrhea and sterility. 

Three varieties of anteflexion have been described: 

I. Corporeal anteflexion, in which the cervix has the 
normal backward direction, and the body of the uterus is 
bent forward upon it (Fig. 80). 




Fig. 80. — Corporeal anteflexion. 



II. Cervical anteflexion, in which the axis of the body 
of the uterus is inclined forward to the normal degree, 
and the cervix is bent forward upon it (Fig. 81). 

III. Cervico-corporeal anteflexion, when the cervix and 
body of the uterus are both bent forward upon each other 
(Fig. 82). 

Anteflexion of the uterus is a disease of single and 
sterile married women. It is very rarely found in women 



ANTEFLEXION OF THE UTERUS. 12 1 

who have borne children. The disease is congenital or 
is caused by imperfect development during childhood. 




Fig. 8i. — Cervical anteflexion. 



The fetal condition of a large cervix and a small, 
sharply-flexed body may persist. The posterior wall of 




Fig. 82. — Cervico-corporeal anteflexion. 

the uterus may develop while the development of the 
anterior wall is arrested, and thus the uterus would be 



122 A TEXT-BOOK OF DISEASES OF WOMEN. 

flexed forward. A mark of such arrest of development 
is sometimes seen in the atrophied or undeveloped ante- 
rior lip of the cervix. Anteflexion is usually accom- 
panied by a small, undeveloped condition of the whole of 
the uterus, and often by poorly developed vagina, tubes, 
and ovaries. 

It is probable that improper dress and hygiene during 
the period of puberty have much to do with the develop- 
ment of anteflexion. The early menstrual history some- 
times points to poor development of the sexual organs. 
The menses often make their appearance much later than 
usual — sometimes when a girl is nineteen or twenty years 
of age — and when established, the function is often 
irregular, the bleeding recurring at long intervals. 

The most prominent symptom of anteflexion of the 
uterus is dysmenorrhea, or painful menstruation. The 
dysmenorrhea is characteristic: violent pains in the center 
of the lower abdomen, extending down the thighs, occur 
for several hours before the bleeding begins. In the later 
years of the disease the pain extends to the whole of the 
pelvis and the back. The pain is caused, in all prob- 
ability, by the accumulation of blood behind the obstruc- 
tion in the cervical canal. When the blood begins to 
escape freely, the pain is relieved, and may be absent 
during the remainder of the menstrual period. The 
blood is often clotted during the first part of the flow. 
Nausea and vomiting may be present during the height 
of the pain. 

The menstrual period may be followed by several days 
of great physical weakness and debility. 

Unless relieved by pregnancy or by proper treatment, 
the anteflexion will persist during the menstrual life of 
the woman. The suffering increases with time. Endo- 
metritis, salpingitis, and ovaritis follow old cases of ante- 
flexion. 

Sterility usually accompanies well-marked anteflexion. 
This may be due to the altered direction of the cervix in 
case of cervical anteflexion, to the obstruction in the 



ANTEFLEXION OF THE UTERUS. 



123 



cervical canal that interferes with the ingress of sperma- 
tozoa, to the generally undeveloped condition of the 
genital organs, or to the inflammation of the mucous 
membrane of the cervix and the body of the uterus. 

The diagnosis of anteflexion is easily made. The cha- 
racter, position, and time of onset of the pain indicate 
some obstruction to the escape of menstrual blood. Vag- 
inal examination reveals the sharp angle of flexion at the 
junction of the body and neck of the uterus. 

Treatment. — If in a case of anteflexion pregnancy 
does occur and runs a normal course^ the disease will be 
cured. After labor the uterus does not return to the 
infantile shape and size. The stimulus of pregnancy 
brings about full permanent development of that organ. 
Miscarriage, however, is very apt to occur during the 
early months of pregnancy, especially in cases of long 
standing. 

Various methods of treatment have been introduced 
for the cure of anteflexion. The object of all these 
methods is the straightening and enlargement of the 
cervical canal. Slow dilatation by graduated bougies 
has been successfully employed. Gradual straightening 
of the canal by the introduction of the uterine sound 
with increasing angle of flexion will also cure some 
cases, if seen early. 

The use of the stem pessary (Fig. 83), 
which is worn continuously in the cervi- 
cal canal, is dangerous and should not be 
practised. 

The best method of treatment consists 
in rapid forcible dilatation with the ute- 
rine dilator. Various instruments have 
been made for this purpose. The prin- 
ciple of all is the same. Two blades are 
introduced, in contact, in the cervical 
canal, and are then separated. Two of these instru- 
ments should be on hand — a small and a large dilator. 
The Goodell dilator (Figs. 84, 85) is so made that the 




Fig. S3.— Stem 
pessary. 



124 A TEXT-BOOK OF DISEASES OF WOMEN. 

blades open parallel with one another, so that the whole 
of the cervical canal is uniformly stretched. 

The best time to perform forcible dilatation is about 
one week after a menstrual period. The woman should 
be etherized and placed in the dorso-sacral position. The 
vagina should be sterilized. All aseptic precautions which 





Fig. 84. — GoodelFs small uterine 
dilator. 



Fig. 85. — Goodell's large uterine 
dilator. 



one would follow in any gynecological operation should 
be observed here. There is always danger of producing 
septic inflammation of the endometrium. The cervix 
should be exposed through the Sims speculum, and the 



ANTEFLEXION OF THE UTERUS. 125 

anterior lip should be seized with the double tenaculum. 
Downward traction on the cervix straightens the cervical 
canal and renders easier the introduction of the dilator. 
The smaller dilator should first be introduced. No force 
should be used in passing it through the cervical canal. 
If an obstruction which cannot be gently overcome is 
met, the dilator should be introduced as far as the ob- 
struction and the blades should then be separated. 
Slight dilatation of this kind below the angle of flex- 
ion will usually enable the operator to pass the instru- 
ment through the cervical canal at a subsequent attempt. 
After the smaller instrument has been introduced to the 
full extent the blades should be gradually separated, for 
a half inch or more, until the canal becomes large and 
straight enough to admit the large instrument. It should 
always be remembered that no force should be used in 
the introduction of either instrument. After introduction 
the blades of the large dilator should be slowly separated. 
On the handles of the Goodell instrument is a graduated 
scale showing the extent of the dilatation. In no case 
should the dilatation be carried beyond one and a half 
inches. In women in whom the cervix and uterus are 
small an inch of dilatation is sufficient. The maximum 
dilatation should be reached slowly and gradually. Lace- 
ration of the cervix or of the margin of the external os 
should be avoided. Sometimes ten or fifteen minutes are 
required before full dilatation is attained. When this 
point is reached the handles should be held in place by 
the screw, and the instrument should be kept in the 
uterus for ten or fifteen minutes longer. The longer 
the dilatation, the more permanent will be the result. 
After the instrument is withdrawn the cervical canal 
and the vagina should be washed out with a I : 2000 solu- 
tion of bichloride of mercury, and a light gauze pack 
should be introduced into the vagina. The pack should 
be removed at the end of forty-eight hours, and a daily 
douche of 1 : 4000 bichloride solution should be admin- 
istered for the following week. The patient should re- 



126 A TEXT-BOOK OF DISEASES OF WOMEN. 

main in bed for two weeks, or longer if there is any pelvic 
pain. Pain, however, does not follow this operation if 
we avoid operating upon those cases in which there is 
inflammatory disease of the tubes and ovaries. The too 
early resumption of the erect position may cause the fail- 
ure of the operation. The abdominal pressure exerted 
upon the fundus uteri, before the organ has become 
fixed in its altered shape, may bring about a recurrence 
of the anteflexion. In case the external os be very small 
— too small to admit the dilators — it may be incised by 
small crucial incisions or reamed out with the closed 
blades of the scissors. 

Dilatation of this kind usually produces a permanent 
broadening and shortening of the cervix. The cervical 
canal is rendered straighter and larger. 

The good effects of the operation are not always appa- 
rent at the menstrual period immediately following the 
operation, because the results of the traumatism to the 
mucous membrane and the structures of the cervix are 
still present. At the periods after this, however, the 
dysmenorrhea is absent or is very much relieved. The 
benefit usually derived from this operation is a strong 
proof of the truth of the obstructive theory of the dys- 
menorrhea. If, after dilatation, conception takes place, 
the woman may look forward to perfect cure. In some 
cases the dilatation does not seem to be sufficient to pro- 
duce a permanent open condition of the cervical canal, 
and the signs of obstruction (dysmenorrhea) return. In 
such a case the dilatation should be repeated. The more 
thoroughly the dilatation is performed the first time the 
less often will the second operation be necessary. 



CHAPTER XI. 

RETROFLEXION AND RETROVERSION OF THE 
UTERUS. 

Retroversion of the uterus means a turning back or 
a backward rotation of that organ. The shape of the 
uterus may not be altered. The fundus, instead of lying 
forward upon the bladder, is directed backward, and 
sometimes lies in the hollow of the sacrum (Fig. 86). 




Retroversion of the uterus. 



Retroflexion means a bending backward of the uter- 
ine axis. The axis of the body of the uterus is normally 
inclined forward at an obtuse angle with the axis of the 
cervix. When the axis of the body of the uterus is in- 

127 



128 A TEXT-BOOK OF DISEASES OF WOMEN. 

clined backward at an angle with the axis of the cervix, 
retroflexion exists. Retroflexion may vary in extent from 
an angle very little less than 180 degrees to an angle con- 
siderably less than 90 degrees (Fig. 87). 




Fig. 87. — Retroflexion of the 



Retroflexion and retroversion usually coexist. The 
conditions are due to similar causes. They may origi- 
nate simultaneously, or one condition, occurriug pri- 
marily, may induce the other. 

An infinite number of degrees of retroversion may 
exist. For convenience of clinical description three 
degrees have been described. In the first decree the 
fundus uteri is directed upward approximately toward 
the promontory of the sacrum. In the second degree 
the uterus lies transversely across the pelvis, the fundus 
and the cervix beinQ- at about the same level. In the 
third degree the retroversion is extreme, and the fundus 
lies below the level of the cervix (Fig. 88). 

Retroversion of the uterus is progressive. It usually 
proceeds from bad to worse. As soon as the downward 



RETROFLEXION AND RETROVERSION. 



129 



abdominal pressure begins to act upon the anterior face 
of the uterus there is a continuous force increasing the 
retroversion. 

There are many causes of retroversion and retroflexion. 




Fig. 88. — Diagram of the degrees of retroversion of the uterus. 

The disease may be congenital. Extreme retroflexion 
has been found in the uterus of the new-born infant. 
Congenital retroversion and retroflexion may be due to 
imperfect development, and resulting imperfect invagina- 
tion of the cervix. The condition may also be caused by 
arrest of development of the posterior wall of the uterus ; 
the anterior wall thus outgrowing the posterior. 

Many cases of retroversion undoubtedly originate dur- 
ing girlhood as a result of falls, blows, distortion of the 
body, or sudden efforts at lifting. The origin of the 
symptoms may be traced in many cases directly to some 
such cause. 

The uterus may be considered to be balanced upon an 

axis running transversely. Anything that turns the 

uterus backward, so that the intra-abdominal pressure 

may act upon the anterior wall, will produce retrover- 

9 



13° A TEXT-BOOK OF DISEASES OF WOMEN. 

sion. It is probable that an over-distended bladder occa- 
sionally acts as a cause of retroversion. 

Retroversion is not at all rare in single women. It 
is very often discovered soon after the establishment of 
the menstrual function, the symptoms of the retrover- 
sion, which probably occurred during girlhood, first 
appearing at this time. Retroflexion, on the other 
hand, except to the slight extent caused by the retro- 
version, is unusual in single women. 

Parturition is probably the most frequent cause of 
retroversion and retroflexion of the uterus. If the woman 
leaves her bed or goes to work too soon after miscarriage 
or labor, many conditions are present that favor retrodis- 
placement of the uterus. The uterus is larger and heavier 
than normal, as a result of imperfect involution: the 
uterine ligaments are lax; the vagina and the vaginal 
orifice are relaxed, and the support of the pelvic floor is 
consequently deficient; the abdominal walls are relaxed 
and the retentive power of the abdomen is diminished. 
It will be remembered that these are the causes that favor 
prolapse of the uterus; in fact, a slight degree of uterine 
prolapse usually accompanies such cases of retrodisplace- 
ment. A certain amount of retroversion must always 
exist before the uterus can pass along the vagina. It 
must turn backward, so that its axis becomes parallel to 
the axis of the vagina. 

Retroflexion occurring after miscarriage or labor is 
sometimes the result of unequal involution in the uter- 
ine walls. If the involution takes place more completely 
in the posterior than in the anterior wall of the uterus, a 
bending back, or a retroflexion, will occur. Such inequal- 
ity of involution may result from inflammation about the 
site of the placenta. 

Retroflexion is a disease of the parous woman, as ante- 
flexion is a disease of the single and the sterile woman. 

Retroversion may be a direct result of laceration of 
the perineum. When the pelvic floor is destroyed and 
the posterior vaginal wall begins to prolapse, it drags 



RETROFLEXION AND RETROVERSION. 



131 



upon the posterior wall of the cervix, and may in this 
way turn the uterus backward. 

Retroversion also results from traction of inflammatory 
adhesions in the pelvis. Cases of chronic inflammation 
of the Fallopian tubes accompanied by inflammation of 
the pelvic peritoneum present adhesions between the pos- 
terior wall of the uterus and the hollow of the sacrum ; 
these adhesions drag the uterus backward (Fig. 89). 




Fig. 89. — Retroversion of the uterus, with adhesions binding it to the anterior 
wall of the rectum and the hollow of the sacrum. 



In cases of retroversion and retroflexion of the uterus 
serious derangement of the circulation results. A state 
of passive congestion follows interference with the ven- 
ous supply. This congestion produces some enlarge- 
ment of the uterus and chronic congestion or inflam- 
mation of the endometrium. Consequently, in all old 
cases of retrodisplacement endometritis is an accom- 
paniment. 



132 A TEXT-BOOK OF DISEASES OF WOMEN. 

Retroversion of the uterus causes traction on the ves- 
icouterine connection, and the neck of the bladder is 
dragged upon ; for this reason irritability of the bladder, 
characterized by frequent and perhaps painful micturi- 
tion, is often present in cases of retroversion. It is not 
uncommon to see women who have received treatment 
directed to the bladder for conditions of this kind that 
disappear immediately when the uterus is restored to the 
normal position. 

The pressure of the displaced fundus upon the rectum 
may also give trouble. Women in this condition often 
complain of a feeling of obstruction in the rectum. 
Pressure upon the hemorrhoidal veins results in hem- 
orrhoids. 

There usually accompanies retroversions of the uterus 
a backward and downward displacement of the ovaries — 
in other words, a prolapse of the ovaries. 

The symptoms of retrodisplacement are numerous, 
and may be referred directly to the altered position of 
the uterus and the accompanying conditions. There are 
backache situated in the upper part of the sacrum, and 
headache situated on the top of the head or in the occi- 
put. These may be considered the two constant symp- 
toms. There is a feeling of weight and dragging in the 
pelvis, extending down the thighs. Physical weakness, 
or inability to walk or stand for more' than a short time, 
is often very marked, and seems to be out of all propor- 
tion to the lesion of the uterus. The manner in which 
such weakness of the legs is produced is not very evi- 
dent. That it is caused directly by the displacement 
of the uterus, however, is proved by the fact that it dis- 
appears as soon as the uterus is restored to its normal 
position. 

The accompanying prolapse of the ovaries produces 
symptoms referable to these organs, the chief symptom 
being pain in each ovarian region. 

The irritability of the bladder has already been spoken 
of. Menorrhagia and leucorrhea may be present as a re- 



RE TROFLEXION AND RE TRO VERSION. 133 

suit of the congestion and the chronic inflammation of 
the endometrium. Menstruation is usually painful. At 
the menstrual period the backache, headache, ovarian 
pain, and vesical disturbance are increased. Dysmen- 
orrhea due to obstruction is unusual in cases of retro- 
flexion. Retroflexion usually occurs in parous women, 
in whom the cervical canal is large, and the flexion 
therefore does not cause sufficient obstruction to impede 
the escape of menstrual blood. All the symptoms aris- 
ing from retroversion of the uterus are ameliorated by 
the recumbent posture. 

The diagnosis of retroversion and retroflexion of the 
uterus is very easily made by bimanual examination. 
The abdominal hand fails to find the fundus in the 
normal position. The vaginal finger feels the cervix 
uteri directed not backward toward the coccyx, but for- 
ward in the direction of the vaginal axis or toward the 
symphysis pubis. The posterior wall of the cervix and 
the body of the uterus may be plainly felt inclined back- 
ward. In case of retroflexion the angle of flexion may 
be felt by the vaginal finger. 

The accompanying prolapse of the ovaries is usually 
very easily demonstrated by vaginal touch. 

Treatment. — As retroflexion does not usually cause 
obstruction of the menstrual flow, the treatment need not 
be directed toward rendering patulous the cervical canal, 
as in the case of anteflexion. Retroflexion is always as- 
sociated with retroversion, and the methods that correct 
the retroversion place the uterus in such a position that 
the intra-abdominal pressure acts on the posterior face 
of the uterus and gradually reduces the flexion. There- 
fore the treatment of retroflexion and of retroversion may 
be considered together. 

Retroversion is treated by the vaginal pessary and by 
operation. 

The vaginal pessary is an instrument to be worn in the 
vagina, and designed to retain the uterus in its normal 
position. A great many different kinds of pessaries have 



134 A TEXT-BOOK OF DISEASES OF WOMEN. 

been invented. The large number of different-shaped 
instruments proves the inefficacy of the pessary as a 
means of treatment in many cases of retroversion. 

The best pessaries for retroversion are the Hodge (Fig. 
90, a), the Smith (Fig. 90, b), and the Thomas (Fig. 90, 
c). These instruments are made of hard rubber. They 






Fig. 90. — Pessaries for retroversion : A, Hodge pessary ; B, Smith pessary ; 
C, Thomas pessary. 

consist of an upper and a lower transverse bar joined by 
two lateral bars. They are so shaped that when intro- 
duced into the vagina they correspond very closely to the 
curvature of the vaginal slit. 

Fig. 91 shows a side view of a pessary in position, and 
it will be observed that the curves of the instrument are 
closely adapted to the curves of the posterior vaginal 
wall, upon which it lies. 

The vaginal pessary retains the uterus in place by 
raising the posterior vaginal fornix and keeping tense 
the posterior vaginal wall. It will be observed that the 
posterior wall of the vagina runs over the upper trans- 
verse bar of the pessary like a rope over a pulley; 
therefore there is maintained a continuous traction in 
an upward and backward direction upon the cervix, and 
a resulting continuous tendency to throw the fundus uteri 
in a forward position (Fig. 91). The tension of the pos- 



RETROFLEXION AND RETROVERSION. 



*35 



terior vaginal wall and the traction upon the cervix vary 
with the position and occupation of the woman, and are 
increased by anything that increases the intra-abdominal 
pressure. 

The vaginal pessary does not maintain the uterus in 
place by pressure upon the body of the uterus, nor does 




Fig. 91. — The retroversion pessary in position. The arrow shows the direction 
of the traction of the posterior vaginal wall upon the cervix. 



the vaginal pessary correct a retrodisplacement. The 
uterus should be restored to its normal position as nearly 
as possible before the pessary is introduced. 

Replacement of the uterus may be effected in one of 
two ways: by bimanual reposition while the woman is 
in the dorsal position; or by instrumental reposition 
while the woman is in the knee-chest position. 

In bimanual reposition the uterus is manipulated be- 
tween the vaginal finger or fingers and the abdominal 
hand until the organ is brought to its normal position 
•of anteversion (Fig. 92). Sometimes this may be more 
easily accomplished by introducing one or two fingers 
into the rectum. 

After bimanual reposition the pessary should be intro 



136 A TEXT-BOOK OF DISEASES OF WOMEN. 

duced in the vagina, and the upper bar of the instrument 
should be carried behind the cervix by manipulation with 
the vaginal finger. 

Bimanual reposition is often difficult or impossible in 
fat women and in those with rigid abdominal walls. 




Fig. 92. — Bimanual reposition of the retroflexed uterus. 

Instrumental reposition in the knee-chest position, 
however, is applicable to all cases in which a pessary is 
indicated. As this method is the one that should in 
general be followed, it will be described in detail. 

The woman should be placed in the knee-chest posi- 



ft 



Fig. 93. — Uterine repositor. 



tion. The perineum should be retracted and the cervix 
exposed with a Sims speculum. It will be observed that 
the cervix is directed forward toward the symphysis 
pubis. The uterine repositor (Fig. 93) is then intro- 
duced, and pressure is made in the posterior vaginal 



RE TROFLEXION AND RE TRO VERSION. itf 

fornix upon the displaced fundus. The fundus may be 
felt with the repositor in this position. Sometimes, by 
grasping the cervix with a tenaculum and drawing it 
downward, the repositor may be applied with better 
effect (Fig. 94). It will often be observed that under this 
pressure the fundus immediately drops forward, while the 




Fig. 94. — Replacement of retrodisplaced uterus by means of the uterine reposi- 
tor, with patient in the knee-chest position (Baldy). 

cervix is turned backward through an angle of 90 or per- 
haps 180 , so that the external os looks no longer toward 
the symphysis pubis, but toward the hollow of the sac- 
rum. The direction of the cervix shows plainly when the 
uterus is in the normal position. Instead of the uterine 
repositor we may use a small firm ball of cotton held in 
long forceps. 

Sometimes it is not possible to make the entire correc- 
tion of the displacement at one time. The uterus may 
perhaps be reduced from retroversion of the third degree 
to that of the first degree, and at a subsequent attempt it 
may be reduced still more, until finally it is brought to 
its normal position. In some cases the difficulty of pro- 
ducing complete reduction at one time is due to the fact 



138 A TEXT-BOOK OF DISEASES OF WOMEN. 




that the woman is unaccustomed to the position and the 
manipulations, and is constantly straining and involun- 
tarily resisting. Complete relaxation of the abdominal 
walls is necessary. 

If the uterus can be reduced to the normal position, 
the pessary may be immediately introduced. If the re- 
duction is not complete, it is best to 
pack the vagina with cotton to 
maintain the degree of reduction 
that has been attained, and to repeat 
the attempt the next day, continuing 
in this way until the uterus has been 
brought approximately to its normal 
position, when the pessary should be 
introduced. The cotton should be 
packed into the vagina in the form 
of balls or pledgets about one and a 
half inches in diameter, which should 
be introduced with the forceps (Fig. 
95) and carefully and tightly packed 
into the posterior vaginal fornix. 
Other pieces should then be packed 
against the anterior aspect of the 
cervix, and then the rest of the va- 
gina should be rather loosely filled. 
The pessary should be introduced 
with the woman in the knee-chest 
position. A number of pessaries, of 
various sizes and shapes, should be 
at hand, in order to have a suitable 
assortment for choice. The pessary 
ig. 95.— tenne oiceps. must be f t ] ie p r0 p er length, breadth, 

and shape ; these requirements differ in various cases. 
The length of the pessary should be such that when the 
upper transverse bar lies in the posterior vaginal fornix 
the lower transverse bar is over the position of the in- 
ternal urinary meatus. The course of the urethra is 
marked by small transverse folds of mucous membrane 




RE TROFLEXION AND RE TRO VERSION. 1 39 

on the middle of the anterior vaginal wall, and the in- 
ternal urinary meatus is situated approximately where 
these small transverse folds cease and become merged 
into the larger oblique folds of the vaginal walls. This 
distance may be measured upon the uterine repositor or 
it may be estimated with the eye. 

It should be remembered that all the dimensions of the 
vagina are exaggerated in the knee-chest position, as the 
vaginal canal is distended by atmospheric pressure. The 
width of the pessary should be such that there is no 
lateral tension put upon the vaginal walls. 

The curvature of the pessary should be such that the 
upper transverse bar does not press upon the posterior 
aspect of the cervix, but is so placed that the posterior 
vaginal fornix is drawn upward and backward. 

The curvature of the pessary may be altered to suit 
any case by dipping the instrument in oil and gently 
heating it over the flame of a spirit-lamp. In this way 
the rubber is softened and may be pressed into any shape. 
While soft and under pressure it should be plunged into 
cold water to set it in the altered form. 

The pessary may be introduced while the perineum is 
retracted with the speculum; or it may be passed into 
the vagina first, the speculum then being introduced and 
the pessary moved into the proper position. The pessary 
should be greased, the lower transverse bar should be 
grasped with the thumb and the index finger, and the 
instrument should be introduced in such a direction that 
one lateral bar lies in the vaginal sulcus. The upper 
transverse bar may readily be placed behind the cervix, 
by manipulation with the finger or the forceps, when the 
perineum is retracted with the speculum. 

The speculum should be removed, and the woman 
should assume the Sims posture for a few minutes. She 
may then get up from the table, and the examination 
may be made in the erect posture, for in this position, 
better than in any other, the fit and the action of the 
pessary may be determined. It will be found that the 



140 A TEXT-BOOK OF DISEASES OF WOMEN. 

lower bar of the pessary is in relation with the anterior 
vaginal wall at the position of the internal urinary 
meatus. It should not protrude from the ostium vagi- 
nae. It should be possible to pass the finger readily 
between the vaginal walls and the lateral and lower 
bars of the pessary. The cervix should be felt directed 
backward through the upper portion of the ring of the 
pessary. It will be felt that the pessary is retained in 
the vagina not by any pressure against the vaginal walls, 
but by a suction — in other words, by the retentive power 
of the abdomen. 

A vaginal douche of warm water should be adminis- 
tered once a day while the pessary is worn. 

The woman should be directed to return for examina- 
tion three days after the introduction of the pessary, or 
sooner if any discomfort is experienced. Sometimes the 
uterus becomes retroverted while the pessary is in posi- 
tion, and becomes flexed over the upper bar of the instru- 
ment, considerable pain resulting. In other cases, where 
the vagina is patulous and too small an instrument is 
used, the pessary becomes turned so that the long axis lies 
transversely. It is well to advise the woman to remove the 
instrument herself if it makes her very uncomfortable. 

The pessary should be examined digitally in the dorsal 
or the erect position, or visually in the knee-chest posi- 
tion. If it is found that the retroversion has returned, 
the uterus should be replaced and a pessary better suited 
in size and shape should be introduced. It is always 
desirable to use as small an instrument as practicable. 
The intervals between examinations may be gradually 
lengthened to two weeks or a month. A woman using 
a pessary should always be under the supervision of a 
physician. The retroversion pessary does not interfere 
with sexual connection. 

The bowels should be carefully regulated. The cloth- 
ing should be supported from the shoulders, not from the 
waist, and heavy lifting should be avoided as much as 
possible. 



RE TROFLEXION AND RE TRO VERSION. 14 1 

After a woman has worn a pessary for three or four 
months, and it is found that the uterus remains in the 
normal position, the instrument should be removed and 
the result carefully watched. 

If the uterus continues in its normal position of ante- 
version, a cure has been accomplished and the pessary 
may be discarded. If the retroversion returns, as it very 
often does, the pessary should be introduced again, and 
an unfavorable prognosis of cure by this means should be 
made. The patient must then choose between the use of 
the pessary for an indefinite period, under medical super- 
vision, and cure by means of an operation. 

The Smith pessary is better adapted to the shape of 
the vagina, which normally narrows from above down- 
ward, than is the Hodge instrument. The Thomas pes- 
sary, in which the upper bar is made very broad, is appli- 
cable to cases of sharp retroflexion with retroversion, in 
which the upper bar may become fixed in the angle of 
flexion in case the retroversion returns. The upper bar 
is made so broad that the angle of flexion would be 
spanned by it in case of such an accident. 

The action of the pessary depends upon the integrity 
of the vagina and the pelvic floor. The retroversion 
pessary, therefore, cannot be used when there is a lacera- 
tion of the perineum. In such a case the perineum must 
always be closed as a preliminary step. 

The pessary should not be used when there is a lacera- 
tion of the cervix uteri, for traction upon the posterior 
lip of the cervix increases the eversion. 

The pessary is contraindicated in all cases in which 
there are pelvic adhesions restraining the uterus, in those 
cases in which there is inflammatory disease of the Fal- 
lopian tubes, and in cases where there is prolapse of the 
ovary, which may be pressed upon by the upper bar of 
the pessary. 

Before making any attempt to replace a displaced 
uterus the physician should always make a careful bi- 
manual examination to determine the existence of any 



142 A TEXT-BOOK OF DISEASES OF WOMEN. 

acute or chronic inflammation of the Fallopian tubes or 
the ovaries. Such inflammation is a contraindication to 
the use of the pessary and to any of the manipulations 
for replacement of the uterus that have already been 
described. 

If the uterus is adherent, the pessary should not be 
used. Cure of the retroversion by it is practically impos- 
sible, and operative treatment is safer and more certain. 

Operative Means of Treating Retrodisplacement 
of the Uterus. — A great many kinds of operation have 
been introduced for curing retrodisplacement of the ute- 
rus. The fundus has been attached to the anterior ab- 
dominal wall by passing a needle and a suture into the 
uterus and thrusting it through the uterine wall and the 
anterior abdominal wall; the uterine cornua have been 
sutured to the anterior parietes ; the round ligaments 
have been shortened by folding each upon itself, and fixed 
in this position by suture; the round ligaments have been 
drawn back through openings made in the broad liga- 
ments and attached by suture to each other and to the 
posterior surface of the uterus; the utero-sacral ligaments 
have been shortened; the uterus has been held forward 
by sutures applied through the anterior vaginal fornix. 

The two operations that have deservedly met with the 
greatest favor are ventro-suspension of the uterus, in which 
the abdomen is opened and the fundus is sutured directly 
to the anterior abdominal wall, and Alexander's opera- 
tion, in which the uterine displacement is corrected by 
shortening the round ligaments as they emerge from the 
inguinal rings. The latter operation is designed to be 
extra-peritoneal. The following is the method of per- 
forming Alexander's operation: 

The uterus should first be replaced as already described, 
and held in position by a gauze or cotton pack. A two- 
inch incision is made from the pubic spine in the direc- 
tion of the inguinal canal. The external inguinal ring 
is opened without wounding the pillars. The thin layer 
of fascia over the ring is divided, the fat is separated, 
and the round ligament is sought with a blunt hook. If 



RE TROFLEXION AND RE TRO VERSION. 143 

the ligament is not found here, the canal may be opened 
to the internal ring. When one ligament has been found, 
it is secured with forceps and the wound is protected 
while the other ligament is secured in a similar way. 
The ligaments are then gently drawn out until they be- 
come tense. If the inguinal canal has been opened, it 
should be repaired by a catgut suture. 

The ligament should be sutured to the pillars of the 
ring by two or three sutures. The excess of the liga- 
ment, sometimes amounting to two or three inches, should 
be cut off. The incision should then be closed. 

The field of this operation is very limited. It is not 
applicable when there are adhesions nor when there is 
disease of the tubes or ovaries requiring operative treat- 
ment. 

Many of the cases of retroversion of the uterus that 
require operative treatment are complicated by salpin- 
gitis and pelvic adhesions, though these extra-uterine 
conditions are very often not recognized by bimanual 
examination before the abdomen is opened. 

The operation that at present seems to possess most 
advantages for the cure of those cases of retroversion of 
the uterus that cannot be cured by the pessary is the 
operation of ventro-suspension of the uterus (Fig. 96). 
It is performed as follows: 

An incision, one and a half to three inches in length, 
is made in the median line of the anterior abdominal 
wall, immediately above the pubis. Two fingers are 
introduced into the abdominal cavity, and the fundus 
uteri is lifted forward. The plane of the abdominal 
incision is exposed, and a curved needle carrying a me- 
dium-sized silk suture is passed through a few fibers of the 
rectus muscle and the peritoneum on one side, immedi- 
ately above the lower angle of the incision. The needle 
is then passed through the tissue of the fundus uteri on 
the line joining the uterine cornua or a little posterior to 
this line. The amount of uterine tissue included in the 
suture is about one-quarter of an inch broad and one- 
eighth to one-quarter of an inch deep. The needle is 



144 A TEXT-BOOK OF DISEASES OF WOMEN. 

then passed through the peritoneum and a few fibers of 
the rectus muscle on the side of the abdominal incision 
opposite the point of entrance. The fascia of the rectus 
should not be included. A similar suture is passed 
about one-third of an inch above this, traversing the 




Fig. 96. — Position of the sutures in ventro-suspension of the uterus. 



uterine wall on a line about one-third of an inch poste- 
rior to the first suture. While the fundus is held forward 
by the finger of an assistant these sutures are tied, so 
that the fundus uteri is brought into contact with the 
anterior abdominal wall. The ends of the sutures are 
cut short. The abdominal incision is then closed by 
three layers of sutures — silk for the peritoneum, catgut 
for the muscle and fascia, and the intra-cutaneous suture 
for the skin. Accompanying disease of the tubes and 
ovaries may be treated directly by this operation, and any 
adhesions may readily be broken. 

In performing this operation it should be remembered 
that we do not wish to make a fixation of the uterus to 



RETROFLEXION AND RETROVERSION. 



145 



the anterior abdominal wall. The inclusion of a broad 
mass of uterine tissue in the suture, and scarification of 
the anterior face of the uterus, which is sometimes prac- 
tised, may result in a broad, unyielding adhesion which 
will interfere with the normal mobility of the uterus and 
with the course of pregnancy and labor. 




Fig. 97. — The suspensory ligament two years after the operation of ventro-sus- 
pension. The ligament measured three inches in length. 



After this operation of ventro-suspension the fundus 

uteri does not remain permanently in contact with the 

anterior abdominal wall. In time it drops somewhat 

backward and downward. The silk sutures drag out a 

ribbon-shaped fold of tissue consisting of peritoneum and 

a little muscle-fiber from the anterior abdominal wall, 
10 



146 A TEXT-BOOK OF DISEASES OF WOMEN. 

and a similar fold of peritoneum and perhaps some mus- 
cular fibers from the uterus, so that in time the uterus 
becomes attached by a slight pliable ligament from one 
to three inches in length (Fig. 97). Bimanual examina- 
tion of the uterus one year after this operation shows 
that the uterus has about the normal range of mobility. 
If this operation is properly performed, the course of sub- 
sequent pregnancies and labors seems to be in no way im- 
peded. 

The operation of ventro-suspension should always be 
accompanied by perineorrhaphy in case there has been 
laceration of the perineum. The two operations may 
be done at the same time. 

The treatment of retrodisplacement of the uterus may 
be briefly summarized as follows: 

The cases of retrodisplacement of the uterus suitable 
for treatment by the pessary are those in which there are 
no adhesions and in which there is no disease of the Fal- 
lopian tubes or the ovaries. If a prolapsed ovary returns 
to its normal position when the displacement of the uterus 
is corrected, it will of course not be pressed upon by the 
bar of the pessary. But in some cases the ovarian pro- 
lapse continues even though the uterus is in its normal 
position, and under such circumstances a pessary usually 
cannot be tolerated. 

The cases that offer the best prospect of cure by the 
pessary are those cases of retroversion, occurring as the 
result of labor, in which the perineum is intact, and 
which are seen within one or two years after the occur- 
rence of the lesion. The prognosis becomes more un- 
favorable the longer the condition has existed before 
treatment. 

Cases of congenital retroversion, or those occurring in 
young unmarried women, are very difficult to cure with 
the pessary. This instrument should always be tried for 
a few months, however, before operative measures are 
advised. In such cases the uterus has been so long in an 
abnormal position that its natural supports have become 



RETROFLEXION AND RETROVERSION. 



147 



permanently altered, and some continuous additional aid 
is necessary to maintain the normal position. 

Every woman who uses a pessary should be under the 
supervision of a physician, and for this reason it is often 
most advisable to recommend immediate operation to 
poor women as the quickest and surest method of cure. 

Immediate operation should always be advised in all 
cases of retroversion with adhesion or with disease of 
the tubes and ovaries. 

It should not be forgotten that we occasionally see 
women with retroversion of the uterus who present no 
symptoms whatever referable to this lesion. In such 
cases no treatment is required. 

Note (in fourth edition). — The operation of ventro- suspension as described 
above has been done by the writer and his assistants 310 times during the past 
seven years, 1893-1 90 1. Two hundred and eleven of these women have re- 
cently made written reports of their condition, which are tabulated as follows : 





Number of cases 
relieved of the 
symptoms for 
which treatment 
was sought. 


1) 

<A 


3 6 


> 


Number of cases 
who became 
pregnant and 
went to full term. 


£ -a 
v 8 


Ventro-suspension with unilateral salpingo- \ 
oophorectomy. J 

Ventro-suspension with perineorrhaphy and ) 
trachelorrhaphy. j 

Ventro-suspension with perineorrhaphy. 

Ventro-suspension with trachelorrhaphy. 

Ventro-suspension alone. 


20 

34 
22 
20 
35 


7 

15 
12 
6 
9 


7 
5 

8 
5 
6 


1 
6 

4 
4 
5 




3 

1 
4 





131 


49 


31 


20 


8 



Of the 20 women who became pregnant and went- to full term, the course 
of pregnancy was normal, and the children were all born alive. One woman 
had a prolonged and difficult labor, though forceps were not used. In 1 case 
forceps were used to deliver a ten-pound child, who presented in occipito-pos- 
terior position; in the remaining 18 cases labor was normal. 

The operation of ventro-suspension seems to have had nothing whatever to do 
with producing the miscarriages. In fact, the number of miscarriages is small 
for any series of 21 1 women, most of whom were of the dispensary class. 

Note. — Since collecting the statistics in the preceding note, we have con- 
tinued to perform this operation in all cases of retroversion suitable for operation, 
with equally satisfactory results. 



CHAPTER XII. 
LACERATION OF THE CERVIX UTERI. 

Laceration of the neck of the uterus is of very fre- 
quent occurrence. It is said that nearly every woman 
suffers with a laceration of greater or less extent at her 
first labor. The majority of such lacerations, however, 
undoubtedly heal during the puerperium and give no 
subsequent trouble. The lacerations that concern the 
gynecologist are those that persist, remaining ununited 
after the woman leaves her bed. The description of the 
injured parts and the treatment therefor will be applica- 
ble to such old cases of laceration. It is true that some 
gynecologists have advised immediate examination and 
the primary operation for repair in case of laceration of 
the cervix, as in case of injury to the perineum; but such 
a course has at present but little endorsement. It is dif- 
ficult to obtain a satisfactory examination under such 
circumstances. A digital examination alone, unless the 
sense of touch be very acute, would often fail to detect 
the lesion in the soft cervical tissue. The woman is 
exposed to the danger of infection of the upper genital 
tract from the manipulations of the examination and the 
operation, and such exposure may be unnecessary, be- 
cause there is no doubt that many lacerations of the 
cervix unite of themselves. 

It has been found necessary to perform the operation 
immediately after labor on account of severe hemor- 
rhage from the lacerated wound. 

Laceration of the cervix may take place in any direc- 
tion, and the injury is described according to the direc- 
tion and number of the tears. A lateral laceration takes 

J48 



LACERATION OF THE CERVIX UTERI. 



149 



place on either side of the cervix. A bilateral laceration 
involves both sides (Fig. 104, a). The left is the more 
usual lateral laceration (Fig. 98), and in case of a bilateral 
tear the injury on the left side is usually the more exten- 
sive. The stellate laceration (Fig. 99) occurs when three 




Fig. 98. — Left lateral laceration of the cervix Fig. 
with erosion. 



-Stellate laceration of 
the cervix. 



or more lacerations radiate from the cervical canal. The 
less common varieties of laceration seen by the gyne- 
cologist are through the anterior and through the poste- 
rior lip. It may be that such lacerations occur as often as 
the lateral lacerations, and that spontaneous repair more 
often occurs, so that they produce no subsequent trouble. 
The relations of the neck of the uterus are such that 
accurate apposition of the injured parts is more likely to 
occur in case of antero-posterior laceration than in the 
lateral form of the injury. In some cases there seems to 
be no doubt that the laceration has extended through the 
posterior lip of the cervix into the cellular tissue above 
the posterior vaginal fornix, and that spontaneous repair 
has taken place, leaving a dense band of scar-tissue to 
mark the site of the lesion. 

An incomplete laceration of the cervix is sometimes 
found. In this injury the tear has extended but part way 
through the wall of the cervix. The mucous membrane 



150 A TEXT-BOOK OF DISEASES OF WOMEN. 

of the cervical canal and the muscular wall of the cervix 

are lacerated, but the injury does not involve the mucous 
membrane of the vaginal aspect, beyond, perhaps, a slight 
splitting of the external os (Fig. 100 ). The lesion is thus 





Fig. 100. — Incomplete laceration of the cervix. 

concealed, and separation of the portions of the cervix is 
prevented. The injury may be detected by introducing 
a sound in the cervical canal and placing a finger on the 
vaginal aspect of the cervix, when it will be found that 
at this spot the point of the sound and the finger are 
separated only by the thickness of the vaginal mucous 
membrane, and not by the normal thickness of the wall 
of the cervix. 

The appearance of a lacerated cervix varies with the 
time that has elapsed since the receipt of the injury. A 
few weeks or months after the occurrence the torn por- 
tions of the cervix will be found, by sight or touch, ly- 
ing in more or less close apposition, the general conical 
shape of the cervix being unaltered. After the lapse of 
a longer period, however, the edges of the laceration be- 
come rounded, and a certain amount of eversion, or turn- 
ing out, of the portions of the cervix takes place, so that 
the mucous membrane of the cervical canal becomes ex- 
posed. This eversion is always most pronounced in the 
bilateral laceration, and is especially striking when the 
tear has extended entirely through the cervix into the lat- 



LACERATION OF THE CERVIX UTERI. 



i.^i 



eral vaginal fornices. In such cases the cervix assumes the 
shape of a split stalk of celery (Fig. 101). The cases of 
laceration with e version of the lips are those in which 
the most marked symptoms are found. When eversion 
occurs, and the mucous membrane of the cervical canal is 
exposed, the shape and ap- 
pearance of the cervix are 
very much altered from the 
normal. Before the true na- 
ture of this lesion had been 
pointed out by Emmet such 
a cervix was said to be ul- 
cerated, the raw-looking sur- 
face, corresponding to the ex- 
posed, irritated, and inflamed 
mucous membrane of the cer- 
vical canal, having been mis- 
taken for an ulcer. Even at 
the present day such a mis- 
take is not infrequently 
made. 

Microscopical examination Fig. ioi.— Bilateral laceration of 

Of SUCh raw-looking Surfaces the cervix with eversion. The dot- 
-i ,-, , , •, • ted line shows the normal shape of 

shows that they are in no . ^ 

J the cervix. 

sense ulcers. "The surface 

is covered with a single layer of epithelium; the cells 
are smaller than those which line the normal cervical 
canal, and, being narrow and long, have a palisade-like 
arrangement; the thin layer of cells allows the subjacent 
vascular tissue to shine through, hence the redness of 
color. The surface is further thrown into numerous 
folds, producing glandular recesses and processes; these 
processes cause the granular appearance of the surface V 
(Hart and Barbour). 

These red patches are larger than the surface of the 
everted mucous membrane of the cervical canal; they are 
continuous with, but extend beyond the limits oi\ this 
mucous membrane. It is said that this increase is occa- 




152 A TEXT-BOOK OF DISEASES OF UVMEJV. 

sioned by proliferation of the epithelium that lines the 
cervical glands. 

As a substitute for the misleading term "ulceration," 
applied to this condition, there have been proposed the 
terms "erosion," "ectropion," or " eversion " of the 
mucous membrane, and "catarrhal patch." 

A true ulcerated surface is sometimes found on a lace- 
rated cervix as a result of excessive irritation, but such a 
condition is rare. 

As the laceration occurs in the cervix before involu- 
tion has begun, this process is impeded, so that a state 
of subinvolution of the cervix results, and the part re- 
mains hypertrophied or much larger than normal. 

The cervical glands share in this condition of subinvo- 
lution, retaining much of the increased size and activity 
that are normal in the pregnant state. 

Changes due to chronic congestion and inflammation 
also take place. The connective tissue increases in 
amount, and the cervix becomes hard, indurated, or 
sclerotic. 

The racemose glands, which open upon the cervical 
mucous membrane, become inflamed, and, as a result of 
change in the consistency of the glandular secretion 
or of obstruction of the gland-orifices, retention takes 
place, with the production of small cysts called Nabothian 
cysts. Such cysts often extend peripherally, so that the 
distal end of the occluded gland approaches the vaginal 
aspect of the cervix, and appears beneath the mucous 
membrane as a translucent vesicle about the size of a 
small pea. Puncture of such a vesicle permits the escape 
of a drop of gelatinous fluid. 

The whole of the body of the cervix may be filled with 
innumerable cysts of this kind, of varying size. When 
projecting beneath the mucous membrane they feel like 
small shot imbedded in the cervix. A cervix in this 
condition is said to have undergone cystic degeneration. 
The inflammation of the lower exposed portion of the 
mucous membrane of the cervical canal extends upward > 



LACERATION OF THE CERVIX UTERI. 153 

so that a condition of general chronic cervical catarrh 
results. This exceedingly common disease is usually 
caused by laceration of the cervix. 

The focus of continuous irritation in the cervix inter- 
feres with the normal involution of the body of the 
uterus, so that there occurs a condition of uterine subin- 
volution, which may be the cause of the chief symptoms 
with which the woman suffers. The endometrium shares 
in the subinvolution, and, as a consequence of this, and 
perhaps also from extension of inflammation from the 
cervical mucous membrane, various forms of endometritis 
may occur. 

In some cases of laceration of the cervix no groove 
corresponding to the angle of the laceration can be felt 
or seen, because it has been filled with a plug or mass of 
cicatricial tissue. In such cases this plug of scar-tissue 
may be felt, distinguished by the palpating finger from 
the softer surrounding tissues of the cervix. 

Symptoms. — The symptoms of laceration of the cer- 
vix uteri are usually referable to pathological conditions 
that are secondary to the laceration, and are in no way 
characteristic. Leucorrhea, or a discharge from the ex- 
posed and inflamed cervical mucous membrane, is usually 
present. Menstruation is often irregular, and is increased 
in duration and amount as a result of the subinvolution 
of the uterus and the chronic congestion, and perhaps 
inflammation, of the endometrium. Backache and ver- 
tical headache may also be present from the same cause. 

If the tear is at all extensive — and especially if it ex- 
tends through the cervix into the cellular tissue of the 
broad ligament — pelvic pain, referred to the general po- 
sition of the scar, may be experienced. 

Movement of the cervix or of the uterus that causes trac- 
tion upon the scar in the broad ligament produces pain. 
Such pain may result from the bimanual examination, 
from jarring or movements of the body, from defecation, 
or from coitus. 

Much of the pelvic pain with which women suffer in 



154 A TEXT-BOOK OF DISEASES OF WOMEN. 

laceration of the cervix is probably due to the pelvic 
lymphangitis and lymphadenitis that are caused by the 
continuous irritation of the diseased cervix. 

Sterility is a not unusual accompaniment of laceration 
of the cervix. It may be due to the malposition of the 
external os or to the profuse cervical discharges. In case 
conception occurs, abortion may follow on account of 
the pathological condition of the body of the uterus and 
of the endometrium. 

Sometimes very marked reflex nervous disturbances are 
caused by a laceration of the cervix. Such disturbances 
are most pronounced in those cases in which there is 
much cicatricial tissue, and in those in which the cervix 
is hard and sclerotic or cystic as a result of long-standing 
inflammation — in other words, in those cases in which 
the substance of the cervix is most affected. 

Neuralgia may occur in any part of the body. It is 
usually situated in the pelvis, or it may extend to the 
groin and down the thigh. Reflex nausea and vomiting 
may result from this as from other lesions of the uterus. 
Cataleptic convulsions and neurasthenia may also result 
from an old laceration of the cervix. The pelvic focus 
of irritation is constantly wearing and exhausting nerv- 
ous energy. 

Diagnosis. — The diagnosis of laceration of the cervix 
is readily made by digital examination. The palpating 
finger feels the one or more angles of laceration. The 
cervix loses its normal dome-like shape and becomes 
broader and flatter. In those cases of bilateral laceration 
where the eversion of the lips of the cervix is so marked 
that the angles of laceration are obliterated — becoming, 
in fact, 1 80 degrees — or where the angles have become 
filled up by a plug of cicatricial tissue, the angles of 
the laceration, of course, cannot be felt. We may often, 
however, detect the presence of the plug of cicatricial 
tissue, which feels harder than the surrounding tissues 
of the cervix; and we can always determine the presence 
of the eversion which seems to have obscured the lesion. 



LA CERA TION OF THE CER VI X UTERI. 155 

As the finger is passed over the flattened presenting 
cervix it is found that the shape is not round, but oval, 
with the long axis antero-posterior. The finger passes 
around a corner or edge as it glides into the anterior or 
posterior vaginal fornix. This corner or edge is the 
extremity of the torn everted lip of the cervix. It corre- 
sponds approximately with the margin of the normal 
external os. The apparent external os, or the opening 
of the cervical canal, which occupies the center of the 
presenting cervix, is really a part of the cervical canal 
higher up than the normal os— a part of the canal that 
has been exposed by the laceration and separation of the 
lips. This fact should be remembered when the length of 
the uterus is measured by the sound. The measurement 
taken from the apparent external os is often half an inch, 
or even one inch, less than it would be if the cervix were 
restored. The degree of subinvolution of the uterus 
indicated by the measurement of the length is often, 
therefore, considerably greater than would be supposed 
after such imperfect measurement. 

The presence of an erosion on the face of the cervix 
may also be determined by palpation. The eroded sur- 
face has a soft and somewhat velvety feeling, in contrast 
with the smooth surface of the normal vaginal cervix 
covered with squamous epithelium. 

The cystic degeneration is readily detected by feeling 
the small shot-like cysts that cover the cervix; and the 
sclerotic condition is indicated by the increased hardness 
or induration, which is easily perceptible to the finger. 

The most satisfactory visual examination of a lacerated 
cervix is made through the Sims speculum, with the 
woman in the Sims or the genu-pectoral position. The 
bivalve speculum, by separating the upper vaginal walls, 
often increases the eversion of the lips and masks the 
lesion. 

The nature of the injury in cases of bilateral lacera- 
tion with eversion may readily be proved in examining 
through the Sims speculum. If the anterior and poste- 



156 A TEXT-BOOK OF DISEASES OF WOMEN. 

rior lips of the cervix be seized with tenacula and then 
drawn together, it will be observed that the area of 
erosion disappears and the normal shape of the cervix is 
approximately restored. 

Treatment. — All forms of laceration of the cervix in 
which there exist eversion, erosion, cystic degeneration, 
and sclerosis should be operated upon. A slight laceration 
in a young woman in the active childbearing period does 
not demand operative treatment if there are no symptoms 
referable to the laceration. In women approaching mid- 
dle life (forty years of age) all lacerations of the cervix 
should be closed, whether or not they produce symptoms. 
It should always be remembered that cancer is most 
likely to originate in a cervix that has been lacerated, 
and the woman should be protected against this danger. 

The treatment of laceration of the cervix is operative. 
A definite mechanical injury has been inflicted, and the 
parts must be repaired by operation. 

The operation for the repair of a lacerated cervix is 
called trachelorrhaphy. The operation consists in denud- 
ing or excising the tissues on the torn surfaces and bring- 
ing the freshened surfaces together with sutures. 

The form of the operation for a bilateral laceration is 
shown in Fig. 104. The operation should preferably be 
performed immediately after a menstrual period. 

The instruments necessary for the operation of trachel- 
orrhaphy are two double tenacula, two sin- 
gle tenacula, tissue-forceps, needle-holder, 
shot-compressor, Sims' speculum, needles, 
(Fig. 102), knife, and scissors, sharp-pointed 
and curved on the flat (Fig. 103). The 

I needles should be spear-pointed and should 

^^ be strong and sharp, as the cervical tis- 
„ . sues through which they are passed are 

Fig. 102. — Cervix- & m . , 

needles. often very dense. The straight or the 

curved needle may be used. 
Silkworm gut, shotted, is an exceedingly good suture- 
material. 




LACERATION OF THE CERVIX UTERI 157 

The woman should be placed either in the Sims or the 
dorso-sacral position. The vulva, vagina, and cervix 
should be thoroughly cleansed and rendered as aseptic as 
possible. The cervix should be exposed through the 
Sims speculum. The anterior and, if desirable, the pos- 




Fig. 103. — Curved scissors for performing trachelorrhaphy. 

terior lip of the cervix should be seized with a double 
tenaculum and held by an assistant; or the lip may be 
transfixed by a silk ligature, with which the cervix may 
be held. 

The denudation, which may be made with a knife or 
with scissors curved on the flat, should be begun upon the 
lower lip. The tissue to be removed may first be marked 
out with the knife. The tissue to either side of the old 
external os is seized with a tenaculum or with toothed 
tissue-forceps, and a strip is elevated by an incision 
extending into the angle of the tear. A correspond- 
ing opposite portion of tissue on the anterior lip is then 
seized in a similar manner, and a similar strip of tis- 
sue is excised, meeting and joining the strip first raised 
in the angle of the tear. We thus remove a wedge- 
shaped portion of tissue. The operation is then repeated 
upon the other side. The strip of mucous membrane 
that is left on the center of the lips to form the new 
cervical canal should be about a quarter of an inch in 
width. 

If the finger be passed over the freshened surfaces, 
small indurated masses of tissue are sometimes felt. 
Such tissue should be caught with the tenaculum or the 



158 A TEXT-BOOK OF DISEASES OF WOMEN. 

forceps and excised. This condition is most usual when 
the tear has been of long standing and the cervix has 
undergone sclerotic changes. It is important that the 
excision of tissue should be carried well up in the angle 
of the laceration, in order that all hard cicatricial tissue 
may be excised. 

The excision of tissue should be done as nearly as pos- 
sible in the plane of the laceration. A frequent mistake 
is to remove too much tissue from the vaginal aspect of 
the cervix. 

There is usually but little bleeding in the operation of 
trachelorrhaphy, and whatever bleeding there is may 
always be controlled by properly placed sutures. 

The first suture should embrace the angle of the lace- 
ration. It should be introduced on the vagiual aspect of 
the cervix, near the edge of the mucous membrane, and 
should emerge on the edge of the mucous membrane of 
the cervical canal. It should then be reintroduced at a 
corresponding point on the opposite lip, and should 
emerge on the mucous membrane of the vaginal aspect. 
It is often difficult to bring the first suture out on the 
mucous membrane of the cervical canal. This, however, 
is not necessary if the suture embraces the whole of the 
denuded angle. 

The other sutures, usually two or three in number, are 
introduced in a similar manner near the edge of the 
mucous membrane of the vaginal aspect, pass around 
the whole of the denuded surface, and emerge on the 
mucous membrane of the cervical canal, near the edge. 
They are then re-introduced on the opposite lip, and 
emerge at a corresponding point on the vaginal aspect of 
this lip. 

A frequent mistake is to bring the sutures out on the 
raw surface so that the lateral union of the torn lips is 
shallow and superficial, often consisting only of the thick- 
ness of the mucous membrane of the vaginal aspect of 
the cervix. As the result of such an operation the new- 
formed cervical canal is spindle-shaped, much broader 



LACERATION OF THE CERVIX UTERI 159 




B 




^SXL 






Fig. 104. — Steps of the operation of trachelorrhaphy for bilateral laceration 
of the cervix uteri : A, bilateral laceration with erosion ; B, the area to be de- 
nuded has been marked out with the knife ; C, the denudation has been accom- 
plished; D, sutures introduced; E, completed operation. 



160 A TEXT-BOOK OF DISEASES OF WOMEN. 

than normal, and the condition of an incomplete lacera- 
tion of the cervix results. 

After the operation the vagina should be washed out 
with a i : 2000 solution of bichloride; it should then be 
dried with sponge or gauze, and a light vaginal pack 
of sterile gauze should be introduced. 

The gauze pack should be removed at the end of forty- 
eight hours, and after this a daily douche, with subse- 
quent drying of the vagina, should be administered. 
The woman should remain in bed for two weeks. There 
is always present some subinvolution of the uterus, which 
is much benefited by rest in the recumbent position. 

The sutures may be removed at any time after two 
weeks. To do this the woman should be placed in the 
lithotomy position. The perineum should be retracted 
with a Sims speculum, and the anterior vaginal wall 
should be supported by an elevator in the hand of an as- 
sistant. 

If a perineorrhaphy is necessary, it should be performed 
at the same time as the trachelorrhaphy. In this case the 
cervix sutures should not be removed for three or four 
weeks, in order to avoid pressure upon the perineum by 
the retracting speculum. 

If there is present marked subinvolution of the uterus 
with accompanying endometritis, the cervical canal 
should be slightly dilated and the body of the uterus 
should be thoroughly curetted immediately before per- 
forming the trachelorrhaphy. 

If the operation of trachelorrhaphy is performed within 
a few months after the receipt of the laceration — before 
sclerotic, cystic, and erosion changes have appeared — 
there is usually required but little preparatory treatment. 
When, however, there is a marked and widespread erosion, 
and the cervix is full of numerous Nabothian cysts, or is 
hard and sclerotic from inflammatory exudate, it is neces- 
sary to devote from two to six weeks to preparation of 
the cervix for operation. Many failures in the operation 
of trachelorrhaphy are due to neglect of such preparatory 



LACERATION OF THE CERVIX UTERI. 



161 



treatment. The hard, cystic cervix may unite but im- 
perfectly after operation, or the symptoms referable to 
the diseased cervix may remain unrelieved by the opera- 
tion. We often see women in whom laceration of the 
cervix has been closed with good union, and yet the scle- 
rotic cystic condition of the cervix, and perhaps subin- 
volution of the uterus, persist, and symptoms continue 
as pronounced as before operation. 

The preliminary or preparatory treatment consists of 
the administration of vaginal douches, regulation of the 
bowels by saline purgatives, and local applications to, 
and puncture of, the cervix uteri. 

The woman should take, two or three times a day, a 
vaginal douche of one gallon of hot water (no° F.). 
The douche should be administered in the recumbent 
posture. 

One or two watery fecal movements should be pro- 
duced daily by Rochelle salts, sul- 
phate of magnesium, or some sim- 
ilar preparation. 

Every five or six days the woman 
should be placed in the knee-chest 
position and the cervix should be 
exposed with the Sims speculum. 
The Nabothian cysts, which ap- 
pear as translucent vesicles be- 
neath the mucous membrane, 
should each be punctured with 
a sharp knife-point. If the cer- 
vix is much enlarged and con- 
gested, it should be freely punc- 
tured over the whole vaginal aspect 
to produce local depletion. Half 
an ounce or an ounce of blood may 
be removed in this way. The cer- 
vix should then be thoroughly 

dried, and an application of Churchill's tincture of iodine 
should be made over the whole of the cervix and the vagi- 
11 




FlG. 105. — Cotton tampon. 



1 62 A TEXT-BOOK OF DISEASES OF WOMEN. 

nal vault. The excess of iodine should be removed with 
a little cotton, and a cotton tampon (to which is attached 
a string) saturated with glycerin should be placed against 
the cervix (Fig. 105). The hygroscopic action of the gly- 
cerin is most useful in depleting the cervix. The woman 
should be told to remove the tampon by traction on the 
string at the end of twelve hours, and to follow the re- 
moval with a vaginal douche of hot water. 

Such local treatment should be instituted immediately 
after a menstrual period and should be repeated every five 
or six days, and continued until the erosion and the cysts 
have disappeared and the induration has diminished. 
Three weeks of such treatment usually produce a very 
marked change. The cervix not onlv becomes much 
more healthy in appearance, but most of the symptoms 
of which the woman complained vanish. The leucorrhea 
diminishes or ceases; the backache and headache dis- 
appear. The relief is often so marked that the patient 
suggests the advisability of deferring operation. This, 
however, should never be countenanced, as all the symp- 
toms will return with cessation of treatment. 

If, after the careful administration of the treatment 
here prescribed for five or six weeks, the induration and 
cystic degeneration do not disappear, then the case is not 
one that will be benefited by trachelorrhaphy. The mere 
closure or union of the indurated and cystic lips of the 
cervix will not cure the woman if these conditions persist. 

If the inflammatory changes secondary to the laceration 
have become so deeply seated that they are not relieved 
by the preparatory treatment, amputation of the cervix 
is necessary. In any doubtful case, therefore, this pre- 
paratory treatment is to a certain extent indicative of the 
character of the ultimate operation to be performed. 

The description of the operation already given is 
applicable to the most usual form of laceration — a bi- 
lateral laceration. If the injury be unilateral, it may be 
necessary to split the cervix on the sound side in order to 
denude, and to introduce sutures, on the injured side. The 



LACERATION OF THE CERVIX UTERI. 



163 



case may then be repaired as in the bilateral form of 
injury. In the case of the unusual stellate laceration the 
lacerations must be separately repaired, or two lacerations 
may be converted into one by excision of the intervening 
tissue. 

The incomplete laceration may be recognized in the 
manner already described, by introducing a sound into 
the cervical canal and a finger in the vaginal fornix. 
Such an injury should be treated by splitting up the 
cervix and converting the incomplete into a complete 
tear, and then denuding where necessary and closing as 
in the case of an open laceration. 

If, in an old laceration, the sclerotic and cystic condi- 
tion of the cervix does not 
yield to the preparatory treat- 
ment advised, amputation of 
the cervix is necessary. 

Amputation of the Cer- 
vix. — This operation is per- 
formed as follows: The cer- 
vix is split bilaterally to the 
vaginal junction with knife 
or scissors. Two flaps are 
formed in this way, and each 
flap is then amputated sepa- 
rately, the posterior one first 
(Figs. 107-109). An incision 
is made on the vaginal aspect 
of the posterior flap, extend- 
ing from the angle of the 
split on one side to the angle 
of that on the other. The 
knife is thrust deeply into 
the cervical tissue and is 
directed toward the cervical 

canal. An incision is then made across the mucous mem- 
brane of the cervical canal, on the anterior aspect of this 
flap. The posterior lip is thus removed. The anterior 




Fig. 106. — An old incomplete 
laceration of the cervix with hyper- 
trophy and cystic degeneration, 
putation is necessary. 



Am- 



164 A TEXT-BOOK OF DISEASES OF WOMEN. 
A B 




Fig. 107.— Operation of amputation of the cervix uteri : A, the cervix has been split laterally, 

forming an anterior and a posterior flap ; B , the posterior flap has been partly amputated. 

A B 




Fig. 108. — A, the posterior flap has been amputated ; B, both flaps have been amputated. 



LACERATION OF THE CERVIX UTERI 



i6q 



lip is removed in a similar manner. The stump of the 
cervix is then closed by sutures. Two or three sutures 
are introduced on each side of the cervix to close the 
angles, just as in the operation of trachelorrhaphy for a 
bilateral tear, and two sutures are introduced on each flap 
to attach the mucous membrane of the cervical canal to 
the mucous membrane of the vaginal aspect, to form the 
new external os. The first sutures should be passed well 



A 


B 


f I -'" 


: 

1 1 / 



Fig. 109. — A, the sutures have been introduced; B, completed operation. 

up in the angles at the lateral vaginal fornices, to control 
bleeding. Bleeding is more likely to be free in this ope- 
ration than in a simple trachelorrhaphy, but it may al- 
ways be controlled by the proper application of the first 
sutures placed in the angles. 

The post-operative treatment is similar to that after the 
operation of trachelorrhaphy. 

Amputation of the cervix does not interfere with con- 
ception, with the course of pregnancy, or with labor. 



CHAPTER XIII. 

INFLAMMATION OF THE CERVICAL MUCOUS MEM= 
BRANE (CERVICAL CATARRH). 

The mucous membrane of the cervical canal may be 
the seat of acute or chronic inflammation. Acute inflam- 
mation usually occurs as part of a general acute process 
affecting the whole of the endometrium, and is com- 
monly the result of gonorrheal or septic infection. It 
will be considered under General Endometritis. 

Chronic inflammation of the mucous membrane of the 
cervical canal (cervical catarrh or cervical endometritis) 
is an exceedingly common affection. Unless caused by 
gonorrhea, it is nearly always secondary to some local or 
general condition. 

The pathological changes that take place in the mu- 
cous membrane resemble those found in a similar pro- 
cess in other parts of the body. There is a very marked 
congestion and hypersecretion of the racemose glands 
of the cervical canal, so that the most prominent symp- 
tom of cervical catarrh, a profuse cervical leucorrhea, is 
produced. This discharge resembles the normal secre- 
tion of the cervical glands. In its physical properties it 
is characteristic. It is a thick, tenacious mucus, and 
differs decidedly from the thin, more serous discharge 
from the vagina or from the body of the uterus. The 
discharge is often opaque ; it is rarely purulent, and is 
very rarely streaked with blood. The mucous membrane 
of the cervical canal becomes swollen, and may project or 
prolapse beyond the limits of the external os, so that the 
external os has around it a ring of red congested mu- 
cous membrane. A similar condition is observed on the 

166 



CERVICAL CATARRH. 167 

eyelids in conjunctivitis. Such a prolapse of the mucous 
membrane would bring the orifices of some of the race- 
mose glands upon the vaginal aspect of the cervix, where 
it will be remembered they are not normally present. 
The inflammatory action extends beyond the limits of the 
external os on to the vaginal aspect of the cervix. The 
squamous epithelium exfoliates over a limited area around 
the external os, and there is produced an erosion resem- 
bling that already described under Laceration of the Cer- 
vix. Consequently, the red eroded area surrounding the 
external os that appears in many cases of chronic inflam- 
mation of the cervical mucous membrane is due to ex- 
tension of the inflammatory process on to the vaginal 
aspect (with desquamation of the superficial squamous 
cells) and to prolapse of the mucous membrane of the 
cervical canal. The racemose glands may become ob- 
structed, either as a result of thickening in the character 
of the secretion or of occlusion of the orifices, and small 
retention-cysts are formed, which often fill the body of 
the cervix, and, extending peripherally, appear beneath 
the mucous membrane of the vaginal aspect. The cer- 
vix is then said to have undergone cystic degeneration. 
Deep-seated inflammatory changes may also take place 
as a result of cervical catarrh, so that at first a slight 
hypertrophy from inflammatory exudate results, and later 
the formation of connective tissue produces a sclerotic 
condition of the cervix. 

As has been said, chronic cervical catarrh, unless of 
gonorrheal origin, is nearly always secondary to some 
local or general condition. The most usual cause of the 
disease is laceration of the cervix, which causes inflam- 
mation of the mucous membrane by direct injury and 
exposure. 

The various flexions and displacements of the uterus 
are often accompanied by cervical catarrh, which proba- 
blv is caused bv the chronic congestion brought about bv 
interference with the circulation of the body and cervix. 
The use of frequent douches of cold water to prevent 



1 68 A TEXT-BOOK OF DISEASES OF WOMEN. 

conception is said to result in chronic inflammation of 
the cervical mucous membrane. 

Imperfect involution after labor, miscarriage, or men- 
struation may cause cervical catarrh from the chronic 
congestion that results. 

Gonorrhea seems in many cases to be communicated 
directly and primarily to the cervical mucous membrane, 
and results in a most obstinate form of chronic inflam- 
mation. 

The scrofulous and tubercular diatheses seem undoubt- 
edly to predispose a woman to chronic inflammation of 
the mucous membrane of the cervix, as of other mucous 
membranes of the body. Cervical catarrh often appears 
in such women without any local lesion to account for it. 
The severity of the local trouble depends upon the gen- 
eral condition, diminishing when the general health im- 
proves. 

In all cases of cervical catarrh, even though dependent 
upon a distinct local lesion like a laceration of the cervix 
or a flexion of the uterus, the severity of the catarrh, as 
measured by the quantity of the discharge, is very much 
dependent upon the general health. The woman is often 
troubled by leucorrhea only at those times at which her 
general health is impaired by overwork, anxiety, or from 
some other cause; and even though the disease may be 
apparently cured by appropriate treatment, the symptom, 
leucorrhea, is very apt to reappear whenever the woman 
is subjected to such depressing influences. 

The most conspicuous symptom of cervical catarrh is 
the leucorrhea — the discharge from the cervical glands. 
As has already been said, in its physical properties it is 
characteristic. It is a thick, opaque, tenacious mucus. 
The quantity is often so great that the clothes of the 
woman are soiled and she is obliged to wear a napkin. 

There may be present slight backache and a feeling of 
vague discomfort or pain in the pelvis as a result of the 
inflammation of the cervix. It is difficult, however, to 
separate symptoms referable distinctly to the cervical 



CERVICAL CATARRH. 169 

inflammation from those due to the primary trouble, to 
which the cervical inflammation is also to be attributed. 
The only one distinct symptom of cervical inflammation 
is the leucorrhea. 

Digital examination in a case of cervical catarrh usually 
reveals an altered condition of the cervix. The vaginal 
cervix may be somewhat enlarged and soft in the early 
stages of the disease, or cystic and sclerotic in the later 
stages. The external os is usually enlarged, often admit- 
ting the tip of the index finger even in those who have not 
suffered with laceration of the cervix. The prolapsed 
mucous membrane is present, and the erosion may be 
readily felt around the external os, being easily distin- 
guished from the smooth, less velvety squamous mucous 
membrane of the vaginal aspect. 

Speculum examination shows a congested vaginal cer- 
vix and a patulous external os around which is the red 
erosion already described. Escaping from the external 
os is seen the thick cervical mucus, which is often so 
tenacious that it may be lifted from the cervical canal 
with forceps. 

The diagnosis of cervical catarrh is usually very easily 
made from a consideration of the signs described. The 
important thing in any case is to determine the cause of 
the inflammation of the cervical mucous membrane, in 
order that the proper treatment may be directed to it. 

Treatment. — As has been said, cervical catarrh is 
always secondary to some local or general condition, 
except in the case of direct gonorrheal infection. The 
gonorrheal cases must be determined by the history of 
the disease and by the distinctive signs of gonorrheal 
infection which will be described later. 

In every case of cervical catarrh a thorough examina- 
tion to determine the local cause of the disorder must be 
made. If, as will usually be the case, such a local cause 
is discovered, the treatment should be applied to it, and 
the inflammation of the mucous membrane may be dis- 
regarded, with confidence that it will disappear when the 



170 A TEXT-BOOK OF DISEASES OF WOMEN. 

exciting cause is removed. Many cases are treated by 
local applications, the whole attention of the physician 
being wrongly directed to the secondary condition, while 
the exciting lesion, such as laceration of the cervix, sub- 
involution, or a flexion or version, is neglected. Such 
treatment, of course, results in but temporary benefit. 

Besides such cases of chronic local inflammation depend- 
ent upon a distinct local lesion, there are many others 
in which the catarrh is but a local manifestation of a 
general state of depressed or poor health, or of a distinct 
dyscrasia like tuberculosis, syphilis, or scrofula. Local 
treatment in such cases, to the neglect of the general 
health, is wrong. 

If the advice here given — to seek for the primary cause 
of the cervical catarrh and to cure it — is followed, it will 
be found that there are but very few cases that depend 
for cure upon local applications. Simple local treatment 
by douches, etc. may, however, be valuable aids in 
hastening the cure of the disease after the exciting cause 
has been removed. 

The treatment may be considered under two heads, the 
general and the local treatment. 

General tonic treatment is required in most cases of 
protracted cervical catarrh. The preparations of iron 
are the most valuable in this condition. 

The contraindication to the use of iron in uterine dis- 
ease is menorrhagia or metrorrhagia — profuse bleeding 
from the uterus. If in any case this symptom is present, 
and it is found that the bleeding is increased after the 
administration of iron, then this drug should be discon- 
tinued. 1 

The following are useful prescriptions in those cases in 
which iron is indicated: 

Blaud's pill, the prescription for which may be written: 
^. Pulv. ferri sulph. exsic, 

Potass, carb. purse, da. 3ij. 

Ut fiat, massa dividenda in pilulas No. xlviii. 
Sig. One pill three or four times a day. 



CERVICAL CATARRH. 171 

Basham's mixture, the formula for which is — 

^. Tinct. ferri chloridi, f^iss; 

Acidi acetici diluti, f 3ij ; 

Liquor, ammonise acetat, f^xiv; 

Elix. aurantii, f3vj; 

Glycerin., flj; 

Aquse, f.liv. 
M. Sig. Tablespoonful after each meal. 

The prescription which Professor Goodell called the 
' ' mixture of the four chlorides ' ' is — 



*. Hydrarg. chloridi corrosivi, 


gr- HJ; 


Iviq. arsenici chloridi, 


gtt. xlviij; 


Tinct. ferri chloridi, 




Acidi hydrochlorici dil., 


da. fsiv; 


Syrupi, 


fSij; 


Aquse, 


ad f£vj. 


M. Sig. One dessertspoonful 


in a wineglassful of 


water after meals. 





This prescription should not be given for more than 
two weeks at a time. 

Careful attention should always be paid to the regu- 
larity of the bowels, in order to prevent pelvic conges- 
tion, which may result from constipation. 

Two or three drams of Rochelle salts may be adminis- 
tered in a tumblerful of water every morning, one hour 
before breakfast. 

A useful prescription, combining the saline purgative 
and the iron, is — 

1^. Ferri sulph., gr. xij; 

Magnes. sulph., oiss; 

Sodii chloridi, gr. xij; 

Acid, sulph. dil., oiss; 

Infus. quassise, ad gvj. 

M. Sig. One tablespoonful one hour before meals. 



172 A TEXT-BOOK OF DISEASES OF WOMEN. 

An excellent laxative pill is — 

3^. Extract, colocynthidis, 

Extract, hyoscyami, ad. gr. x; 

Massse hydrargyri, gr. xx. 

M. Fiat massa dividenda in pilulas No. xx. 
Sig. One pill three times a day. 

Strychnine in addition to the iron is often a most use- 
ful medicine in cervical catarrh. 

Various medicines have been administered internally 
to control the hypersecretion from the cervical glands. 
Such therapeutics, however, is not to be relied upon. 

Any distinct pathological condition, like tuberculosis 
or syphilis, should, of course, receive the appropriate 
treatment. 

Local treatment may be directed to the vaginal aspect 
of the cervix or directly to the cervical canal. The 
former treatment should always be tried first, and it will 
usually be found sufficient. It consists of the administra- 
tion of hot vaginal douches, the application of Churchill's 
tincture of iodine to the vaginal vault, and the use of the 
glycerin tampon as described under the treatment of 
laceration of the cervix. Puncture of the cervix in order 
to produce local depletion, as already mentioned in the 
preparatory treatment of laceration of the cervix, may 
also be tried. 

If any case of cervical catarrh persists after the cure 
of the primary local or general lesion, in case such a 
lesion is present, and after the additional local treatment 
by douches and applications to the vaginal vault, then 
we may be obliged to make applications directly to the 
mucous membrane of the cervical canal. 

These applications should be made as follows, any time 
in the menstrual interval being appropriate: The cervix 
should be exposed through the Sims or the bivalve spec- 
ulum, and should be steadied by seizing it with a tenac- 
ulum. The cervical canal should then be wiped out 
with cotton either in the grasp of long thin forceps or 



CERVICAL CATARRH. 173 

upon an applicator. The cervical mucus should be re- 
moved in this way, in order to permit the direct applica- 
tion of the desired solution to the mucous membrane. 
The applicator or forceps, armed with cotton saturated with 
the solution, should be introduced in the cervical canal 
and applied to all portions of the mucous membrane. 

In place of the applicator we may use the glass pipette 
or instillation-tube (Fig. no), as recommended by Skene. 




Fig. 1 10. — Instillation-tube. 



This instrument, charged with a few drops of the solu- 
tion, should be introduced as far as the internal os, and 
the solution should be expressed as the pipette is slowly 
withdrawn. 

In most cases of cervical catairh the external os is suf- 
ficiently large and the canal sufficiently patulous to per- 
mit the applications already described. Sometimes, how- 
ever, when the external os and the canal are contracted, 
it is desirable to dilate slightly with the small uterine 
dilators before making the application. Such dilata- 
tion to one-quarter or one-half an inch may be per- 
formed without an anesthetic, and may be repeated as 
often as necessary. 

Various solutions are used for application to the cervi- 
cal canal. Violent caustics should be avoided. The 
solutions of mild strength are preferable. A solution of 
1 or 2 grains to the ounce of chloride of zinc, sulphate 
of zinc, tannic acid, nitrate of silver (5 to 10 per cent.), or 
bichloride of mercury (1 : 1000) is often useful. An appli- 
cation of pure carbolic acid is sometimes followed by good 
results. Perhaps the most generally useful application is 
Churchill's tincture of iodine or a solution of 2 parts of 
tincture of iodine and 1 part of carbolic acid. 



CHAPTER XIV. 
CONGENITAL ER05I0N AND SPLIT OF THE CERVIX. 

In describing the lesions of laceration of the cervix and 
cervical catarrh, frequent mention has been made of the 
cervical erosion or the catarrhal patch. The erosion, 
or red granular area, surrounding the external os seems 
to be caused by various factors. In laceration it is due 
to the eversion and exposure of the normal cervical 
mucous membrane, and perhaps to slight proliferation 
of the cylindrical cells of this mucous membrane on 
to the mucous membrane of the vaginal aspect of the 
cervix. In cervical catarrh it is caused by swelling 
and prolapse of the mucous membrane of the cervical 
canal, and extension of the inflammatory process beyond 
the limits of the external os, with partial desquamation 
of the squamous cells. 

There are other cases, however, in which the erosion 
appears to be congenital. Such erosions have been ob- 
served by Fischel and other investigators surrounding the 
external os in new-born infants. Erosion of this cha- 
racter has been found, in a more or less marked degree, 
in 36 per cent, of new-born infants. Microscopically, 
these erosions appear to be a direct continuation of the 
mucous membrane of the cervical canal. They are 
covered with a single layer of cylindrical epithelium, 
and they possess mucous glands, resembling in these 
features the cervical mucous membrane, and not the 
mucous membrane of the vaginal aspect of the cervix, 
which, it will be remembered, is covered with squamous 
epithelium and contains no glands. This congenital 
erosion usually is of very limited extent, but in some 
cases it covers the greater part of the vaginal aspect of 

174 



CONGENITAL CERVICAL EROSION. 



175 



the cervix, and may then give rise to decided symp- 
toms. The condition is due to imperfect development of 
the external os. In the well-formed woman there is, at 
the external os, a sharp line of demarcation between the 
squamous epithelium of the vaginal aspect and the cylin- 
drical epithelium of the cervical canal. In the congenital 
erosion the epithelium of the canal extends beyond the 
limits of the external os, and meets the squamous epithe- 
lium at a lower level than normal. 

Such congenital erosions usually give rise to no trouble, 
though perhaps they predispose the woman to cervical 
catarrh as a result of exposure of the mucous membrane. 
In extreme cases, however, in which the cylindrical epi- 
thelium of the cervical canal persists over the greater 
part of the vaginal cervix, and in which the glandular 
elements of the canal are found on the vaginal aspect, a 
distinct pathological condition arises. The symptoms of 
this condition resemble closely those of laceration of the 
cervix with ectropion. There is backache, a feeling of 
weight in the pelvis, and perhaps 
some ovarian pain. In addition, 
the woman complains of a leucor- 
rhea presenting the characteristics 
of the cervical mucus. Decided 
nervous and digestive disturbances 
may be present. 

If this condition of congenital 
ectropion exists along with a lace- 
ration of the cervix, the diagnosis 
becomes very difficult. If, how- 
ever, we can exclude the possibil- 
ity of a former conception, we may 
by careful study determine the real 
nature of the case. 

Fig. in represents the appear- 
ance of the cervix in a case of 

marked congenital erosion in a virtuous single woman 
twenty years of age. It will be observed that the appear- 




FiG. ill. — Congenital ero- 
sion of- the cervix. 



176 A TEXT- BOOK OF DISEASES OF WOMEN. 

ance resembles somewhat that seen in a bilateral lacera- 
tion of the cervix with eversion. The following are the 
points of difference: 

In laceration — 

There is a history of previous pregnancy. 

The presenting face of the cervix is oval, with the long 
axis antero-posterior. 

The angles of laceration may be determined, by sight 
or touch, either as more or less well-marked depressions 
or as hard plugs in case they are filled up by scar- 
tissue. The mucous membrane of the cervical canal may 
be made out as a strip on the anterior and posterior lips, 
from which there extends laterally a more or less well- 
marked erosion. 

The vaginal cervix is not of the general mushroom 
shape seen in the figure. 

If microscopic examination of the cervix be made, 
racemose glands will be found discharging only on the 
mucous membrane of the cervical canal — not all over the 
vaginal aspect. 

In the congenital ectropion — 

There may be no history of pregnancy. 

The presenting face of the cervix is approximately 
circular. 

There is no angle of laceration determined by sight or 
touch. 

The erosion may extend evenly around the external os, 
and there is no one strip that corresponds to the exposed 
mucous membrane of the cervical canal. 

The vaginal cervix is mushroom-shaped, with a decided 
stalk. 

Microscopic examination reveals racemose glands dis- 
charging over the greater part of the vaginal cervix, to the 
sides of the external os, as well as in front of and behind it. 

The ultimate test of this condition is the discovery of 
the glands discharging on the vaginal aspect of a cervix 
in which the mucous membrane of the cervical canal had 
not been exposed by laceration. 



CONGENITAL CERVICAL EROSION. 177 

The treatment of congenital erosion of the cervix, 
when it is so marked as to produce distinct symptoms, is 
amputation of the cervix. 

Congenital Split of the Cervix. — There is some- 
times found a congenital split of the cervix, closely re- 
sembling a unilateral or bilateral laceration following 
labor or miscarriage. The recognition of this fact is of 
great medico-legal importance. One of the most positive 
signs of a former conception is a laceration of the cervix. 
In some cases, however, a condition resembling such a 
laceration may exist from birth. Marked lateral split of 
the cervix has been discovered in the new-born infant, 
and several cases have been observed in which this con- 
dition has been found in adults of undoubted virginity. 

It is possible that this condition may become patho- 
logical. Cervical catarrh might be produced from expos- 
ure of the mucous membrane of the cervical canal. The 
lesion, however, is not of nearly such serious moment as 
a laceration after miscarriage or labor, for the last injury 
occurs in a uterus which must undergo involution, and 
the chief symptoms of laceration of the cervix are usu- 
ally those incident to arrested involution. 



12 



CHAPTER XV. 

CERVICAL POLYPI; HYPERTROPHIC ELONGATION 
OF THE CERVIX; CHANCRE OF THE CERVIX; 
TUBERCULOSIS OF THE CERVIX. 

Cervical Polypi. — Polypoid tumors are found grow- 
ing from the mucous membrane of the cervical canal, 
projecting into the canal or protruding from the external 
os. The mucous polypus is the most usual form, and is 
caused by cystic degeneration of the Nabothian glands 
of the cervical mucous membrane. Sometimes such 
polypi protrude from the ostium vaginae. Less often 
a papillary or warty growth is found on the mucous 
membrane of the cervical canal, in the neighborhood of 
the external os. There is usually present dilatation of 
the external os and cervical canal. The symptoms 
of cervical polypi are not characteristic. Inflammation 
of the cervical mucous membrane and cervical catarrh 
may result. There may be slight, and rarely profuse, 
bleeding from the external os. The bleeding may follow 
efforts at straining, sexual connection, long standing, or 
exercise. Occurring at the time of the menopause or 
later, this symptom would excite the suspicion of begin- 
ning cancer of the cervix. 

Pediculated polypi should be twisted or cut away. 
Bleeding is usually very slight. The sessile growths, 
like the papillomata, should be excised, the incision be- 
ing carried well below the base of the tumor into the 
healthy tissue of the cervix. The wound may then be 
closed with an interrupted suture. In every case of such 
tumor a careful microscopical examination should be 
made to determine its benign or malignant character. 

Hypertrophic Elongation of the Vaginal Cervix. 

178 



CEP VICAL POL YPf, E TC. 



179 



— In this condition there is a marked increase in the 
length of the vaginal portion of the cervix uteri, though 
the thickness of the cervix may be but little, if any, 
greater than normal. The vaginal cervix may be so long 
that the external os may lie outside the ostium vaginae. 




Fig. 112. — Mucous 


i polyp of cervix. 




"ik 


W 






00 



Fig. 113. — Cervical polyp. 



The condition is a true hypertrophic growth, the cause 
of which is unknown. It is probably congenital, as it is 
found in the virgin. 

The diagnosis between elongation of the vaginal cervix 
and the various forms of prolapse of the uterus and the 



180 A TEXT-BOOK OF DISEASES OF WOMEN. 

vagina may be readily made. In elongation of the vag- 
inal cervix the fundus uteri is at the normal level; there 
is no inversion of the vagina; the vaginal fornices are in 
the normal position. 

Elongation of the vaginal cervix to a degree sufficient 
to be considered pathological is very rare. 

The treatment consists in amputation of the cervix. 

Chancre of the Cervix. — Chancre of the cervix is a 
rare lesion. One observer, Rassennone, found 117 uter- 
ine chancres in a series of 1375 cases of venereal sores on 
the female genitals. The sore may occur on either lip 
of the cervix and may extend into the cervical canal. 
The appearance is that characteristic of similar sores in 
other parts of the body. 

The diagnosis may be made from a history of coitus 
with a man having active syphilis, by microscopic exam- 
ination if necessary, and by the later appearance of sec- 
ondary syphilitic symptoms. 

Tuberculosis of the Cervix.— Tuberculosis of the 
cervix is a very rare condition. The appearance of the 
cervix in such cases resembles that of cancer. In fact, 
hysterectomy has been performed for this condition 
under the mistaken diagnosis of malignant disease. 

The diagnosis may be made by the microscopic exam- 
ination of the discharge and of excised tissue. 

Complete hysterectomy should be performed for tuber- 
culosis of the cervix. 



CHAPTER XVI. 
CANCER OF THE CERVIX UTERI. 

Cancer of the cervix uteri is a very common disease. 
About one-third of all cases of cancer in women affect 
the uterus. Like cancer in other parts of the body, the 
disease has been observed at almost every period of life 
except infancy. It occurs most frequently during the 
active mature life of the woman, between the ages of 
thirty and fifty. It is probable that more cases occur 
during the latter decade of this period than during the 
former. 

Cancer of the cervix is a disease of the childbearing 
woman. It is very rare in women who have never con- 
ceived. Statistics show that women who develop cancer 
of the cervix have borne on an average five children. 
The stout, well-nourished mother of a large family is 
very prone to cancer of the cervix. 

It is probable that the chief predisposing cause of can- 
cer of the cervix is a fissure or laceration caused by mis- 
carriage or labor. A focus of irritation, an area of dim- 
inished resistance, is thus developed, where cancer may 
start in a woman predisposed to this disease. In some of 
the cases of cancer of the cervix occurring in sterile 
women it has been found that previous traumatism had 
been inflicted by dilatation or incision of the cervix. 

Cancer of the cervix uteri originates in one of three 
structures: I. The squamous epithelium covering the 
vaginal aspect of the cervix; II. The cylindrical cells 
lining the cervical canal; III. The epithelial cells of the 
cervical glands. The first variety is called squamous- 
cell carcinoma of the cervix. The second and third 
varieties are called adeno-carcinoma of the cervix. 

181 



182 A TEXT-BOOK OF DISEASES OF WOMEN. 



The early appearance of the disease, the gross form 
assumed by the cancer, the direction of growth, and the 
clinical course depend upon the place of origin. In the 
late stages of the disease, characterized by extensive de- 
struction of tissue, all forms appear alike. 

I. Cancer of the vaginal aspect of the cervix (squamous- 
cell carcinoma) very often begins in a benign erosion of 
an old laceration. The early stages of transition from 
the benign to the malignant condition are not apparent 
to the unaided senses, and can be recognized only by the 
microscope. Later a superficial ulceration is developed, 




Fig. 1 14. — Cancer of the vaginal aspect of the cervix. 

or the cancer may assume the polypoid or vegetating form, 
and become readily recognized by the unaided senses. 

It will be remembered that true ulceration as a benign 
condition is very rare on the cervix uteri. The erosion 
of a laceration is in no sense an ulceration. An ulcera- 
tion of the cervix, therefore, should always excite the 
gravest suspicion. The polypoid or vegetating growths 
vary very much in size. They are sometimes very exu- 



CANCER OF THE CERVIX UTERI. 



183 



berant, forming large cauliflower-like masses filling the 
upper part of the vagina (Fig. 114). In other cases they 
are small warty growths or rounded protuberances about 
the size of a' pea. The disease usually spreads to the 
mucous membrane of the vagina. Less often it extends 
to the cervical canal and to the body of the uterus. 

II. When the cancer begins in the mucous membrane 
of the cervical canal (adeno-carcinoma), extensive de- 
struction of tissue may take place before any appearance 




Fig. 115. — Cancer of the cervical canal, with metastasis to the vagina. 



of the disease is observed at the external os (Fig. 115). 
This is most likely to occur in those cases in which there 
is not present a bilateral laceration of the cervix with 
eversion of the mucous membrane. In some cases the 
whole of the cervix is destroyed, leaving only a shell, the 
lower portion of which is the vaginal aspect of the cervix. 
When the cervix is lacerated and the mucous mem- 
brane of the canal is exposed, the disease is more early 
apparent, and we may then observe the malignant ulcera- 



A TEXT-BOOK OF DISEASES OF WOMEN, 



tion of the exposed mucous membrane or the presence 
on it of cancerous outgrowths. This form of cancer of 
the cervix uteri is more likely to extend upward to the 
endometrium than is the form first described. 

III. When the cancer begins in the distal ends of the 
cervical glands (adeno-carcinoma), it may appear as a nod- 
ule in the body of the cervix. It will be remembered that 
sometimes these glands become so distended peripherally 
that they appear beneath the mucous membrane of the vag- 
inal aspect of the cervix as Nabothian cysts. In a similar 
way, when the glands become seats of cancerous infection^ 




Fig. 116. — Nodular cancer of the neck of the uterus (a) (Ruge and Veit). 

hard nodules of various size may appear or be felt beneath 
the vaginal mucous membrane. In other cases the nodule 
is situated beneath the mucous membrane of the cervical 
canal. These nodules disintegrate and perforate the 
overlying mucous membrane, and in this way form a 
malignant ulcer which may appear either in the cervical 
canal or on the vaginal aspect of the cervix. 

As has been said, when ulceration and destruction take 



CANCER OF THE CERVIX UTERI. 185 

place, in the last stages of the disease, all the varieties of 
cancer present a similar appearance and are accompanied 
by similar symptoms. 

Cancer of the cervix uteri may extend to the vagina, 
to the body of the uterus, to the broad ligaments, the 
bladder, rectum, ureters, and the peritoneum, and it may 
be carried by the lymphatic vessels to the pelvic and 
inguinal lymphatic glands. 

In nearly all cases of long standing the upper part of 
the vagina is involved. Sometimes the whole of the 
vaginal canal, from the cervix to the vulva, is infiltrated 
with cancerous growths. 

The body of the uterus always becomes involved sooner 
or later. This is most apt to occur in those cases in 
which the disease begins in the cervical canal. The 
endometrium is affected by direct extension, the malig- 
nant disease being often preceded by some benign form 
of endometritis. 

Sometimes the cervix becomes hypertrophied by general 
infiltration to three or four times its usual size. 

The broad ligaments are very usually involved by direct 
extension of the disease. They become thick, hard, and 
very rigid, holding the uterus fixed in the pelvis. When 
only one ligament is affected, the uterus is drawn to that 
side. The ureters become involved by extension of the 
infiltration to their walls or by pressure upon them by 
the thickened broad ligaments. 

The bladder, on account of its close relationship to the 
cervix, is always involved in the last stages. The disease 
may extend to the vesical mucous membrane, and symp- 
toms of cystitis will appear. Sometimes the vesicovag- 
inal septum is destroyed and a urinary fistula results. 
Extension to the rectum is not so common. As the dis- 
ease extends upward the peritoneum may be perforated, 
though this is an unusual accident. In most cases peri- 
toneal involvement is preceded by local inflammation and 
by adhesions which prevent direct penetration of the 
peritoneal cavity. 



186 A TEXT-BOOK OF DISEASES OF WOMEN. 

The pelvic and retroperitoneal lymphatic glands be- 
come affected in the later stages of cancer of the cervix. 

The inguinal glands are rarely involved in the last 
stages of the disease. Metastasis to remote parts of the 
body is unusual. Cancer of the cervix usually remains 
localized and does not become metastatic. 

From this description it will be observed that in the 
early stages of cancer of the cervix the disease presents a 
variety of appearances. As cure of the disease depends 
upon its early recognition, it is of the utmost importance 
that the physician should be familiar with these early 
phenomena. 

When cancer begins in an erosion of a laceration, we 
find that the eroded surface bleeds more easily than in the 
non-malignant condition, and is somewhat more elevated 
than the surrounding surface of the cervix. We may by 
palpation detect around the erosion a more or less in- 
durated edge which is not felt around a benign erosion. 
The submucous structures of the cervix may feel brawny 
and indurated. If the erosion has become an ulcer, the 
indurated edges and the involvement of the deeper struc- 
tures of the cervix are more marked. It must always be 
remembered that an ulcer of the cervix is very rare as a 
benign condition. 

In the vegetating form of cancer of the cervix we may 
find small warty growths, or large cauliflower-like masses, 
or rounded or irregular protuberances growing from the 
surface of the cervix. There is here also felt an indura- 
tion around the base of the growth and throughout the 
cervix. 

A very striking characteristic of cancerous growths of 
the cervix uteri is their friability. The warty growths 
or cauliflower-like masses break off readily upon even 
gentle palpation, and profuse bleeding often results. 
There is no other disease of the cervix in which the 
outgrowths are of such a friable and vascular character. 
Even in the ulcerated form of cancer the edges of the 
nicer are of this same friable nature. 



CANCER OF THE CERVIX UTERI. 187 

When the disease begins immediately within the ex- 
ternal os, this opening becomes enlarged, the cervical 
canal is destroyed, and there is presented the appearance 
of a deep conical excavation, with ulcerated, unhealthy 
edges, in the center of the vaginal cervix. When the 
disease begins still higher up, the cervical canal may be 
the seat of extensive destruction of tissue before any 
lesion is visible below the external os. Usually, how- 
ever, the os is sufficiently open to permit the condition 
of the canal above to be seen. 

When the disease begins in the racemose glands of the 
cervix, the nodules may be felt beneath the mucous mem- 
brane of the vaginal aspect of the cervix. The whole 
cervix is usually indurated and somewhat enlarged. The 
mucous membrane overlying the nodule may appear con- 
gested, and upon palpation it is found that the overlying 
mucous membrane does not glide readily over the nodule, 
but seems to be more than normally adherent to the 
underlying structures. 

In all the forms of cancer of the cervix there is present 
to a greater or less extent a general induration of the 
cervix. The elasticity or resiliency of the cervix is 
diminished or lost ; this is shown not only by the sensa- 
tion upon palpation, but by the fact that the cervix is 
not capable of dilatation, by sponge tent or otherwise, as 
in the normal condition. 

In the last stages of the disease the gross appearance 
is the same in all forms of cancer of the cervix. The 
cervix may fill the whole vaginal vault, sometimes hyper- 
trophied to the size of the adult fist. The presenting 
mass is ulcerated, gangrenous, and covered with friable 
vegetations bathed in thin fetid pus and blood. The 
vaginal vault itself is usually involved by extension of 
the disease. The body of the uterus is found to be en- 
larged, and the mass of the cervix is held rigidly in the 
pelvis by the thickened cancerous broad ligaments. 

In some other cases, instead of a protruding mass we 
discover an immense crater in the vaginal vault — a era- 



1 88 A TEXT-BOOK OF DISEASES OF WOMEN. 

ter with indurated edges and sides, surmounted by the 
body of the uterus. The size of the crater shows that 
the destruction of tissue has extended far beyond the 
normal limits of the vaginal and supra-vaginal cervices. 
The interior of the crater presents an ulcerated, slough- 
ing surface. 

There is no condition which should be mistaken for 
cancer of the cervix in the last stages. A sloughing 
uterine polyp presents superficially a similar appearance, 
but the gangrenous mass will be found surrounded by a 
ring or collar, often very attenuated, of healthy cervical 
tissue, and the presenting tumor is usually elastic to the 
touch, not unyielding and friable like the cancerous mass. 

In the early stages of cancer the appearance resembles 
closely the erosion of a bilateral laceration of the cervix. 
In the simple laceration, however, the erosion is soft, not 
indurated; there are no palpable edges; the cervix is not 
brawny; and it will be found that the simple erosion 
yields to local treatment, while the cancerous erosion 
does not. 

Syphilitic ulceration and the ulceration of lupus are 
very rare upon the cervix. Syphilitic ulceration some- 
times presents all the gross appearances of cancer. The 
history, the microscopical examination, and the thera- 
peutic test will enable one to make a differential diag- 
nosis. 

Cystic degeneration of the cervix should not be mis- 
taken for the nodular form of cancer, for the cysts may 
be seen and punctured and their character determined. 

Benign fibroid tumors of the cervix are very rare, 
are usually single, and are larger than the nodules of 
cancer. 

In every case of doubt, in every case in which the 
physician has the least cause to suspect malignancy, 
microscopic examination of an excised portion of tissue 
should be made. Examination of tissue scraped off 
should not be relied upon. The most suspicious portion 
of tissue should be seized with a tenaculum and freely 



CANCER OF THE CERVIX UTERI. T.89 

cut out. Pieces of tissue may be thus excised from two 
or more situations. In the nodular form of cancer a 
nodule should be seized and excised. It is perfectly 
justifiable, in cases which cannot thus be elucidated, to 
amputate the cervix and examine the whole structure. 

The excision of small pieces of tissue may be done 
without an anesthetic, as little or no pain is caused by 
the operation. Bleeding is very slight, and may always 
be controlled by a light vaginal compress of gauze or 
cotton. If the case is not malignant, healing is rapid. 
The specimen removed should be placed in absolute 
alcohol and submitted to microscopical examination by an 
experienced pathologist. 

Symptoms of Cancer of the Cervix. — A study of 
the early symptoms of cancer of the cervix is of the 
greatest importance. In the early stages the disease may 
be eradicated with every probability of permanent cure. 
Cancer of the uterus is more favorable for surgical attack 
than cancer in most other parts of the body. Excision 
of the disease is not done in the continuity of an organ 
or a structure, but the whole organ attached by distinct 
structures may be removed. 

The great majority of women with cancer of the cer- 
vix come to the operator when the disease has extended 
too far to permit any radical treatment. Hopeless pal- 
liation is the only course to be followed. This unfortu- 
nate condition of things is due to the ignorance of the 
woman in regard to the significance of the early symp- 
toms of the disease, and to the failure of the physician 
first consulted to insist upon a thorough examination as 
soon as any suspicious symptoms appear. 

There is no one symptom of cancer of the cervix 
present in all cases, and all the common symptoms may 
be absent in exceptional cases until the last stages of the 
disease — until the disease has extended so far that cure 
is impossible. It is of great importance to remember this 
fact, so that the absence of one or more of the classical 
symptoms of cancer shall not engender a feeling of secur- 



19° A TEXT-BOOK OF DISEASES OF WOMEN. 

ity that may cause the postponement of a thorough 
physical examination. 

The usual symptoms of cancer of the cervix are hem- 
orrhage, pain, and discharge. 

Hemorrhage. — The first symptom that should direct 
our attention to this disease is bleeding from the vagina. 
Such hemorrhage often first appears as a menorrhagia — 
as an increase in the amount of blood lost at the normal 
menstrual periods. The loss of blood may be greater, 
and the duration of the period longer. Sometimes, if 
the woman keeps quiet during the period, the loss of 
blood and the duration are about as usual; but if she is 
upon her feet the loss is increased, and if she begins an 
active life immediately after the usual duration of the 
menstrual period has elapsed, bleeding may reappear for 
one or more days. 

In other cases slight bleeding appears in the menstrual 
interval. A spot of blood may be discovered upon the 
clothing. The accustomed leucorrheal discharge may 
occasionally be streaked with blood. Such appearances 
are most frequent after long walking or standing or phys- 
ical work, or after straining at stool, or very often after 
coitus. 

If the woman has passed the menopause, the hemor- 
rhage of cancer may appear as a re-establishment of men- 
struation — often to the satisfaction of the woman. This 
post-climacteric bleeding may occur with more or less 
regularity — every month or every three or four months — 
or it may appear as an occasional loss of blood after un- 
wonted effort. 

All hemorrhage of this kind, in women over thirty 
years of age, demands immediate and careful physical 
examination. Any bleeding from the vagina in a woman 
who has passed the menopause should arouse the gravest 
suspicion. From the slight hemorrhages just described 
the bleeding increases in intensity and duration, until 
there is a continuous loss of blood that saps the strength 
of the woman and produces the profound anemia cha- 



CANCER OF THE CERVIX UTERI. 191 

racteristic of the last stages of cancer of the cervix, 
Sudden fatal hemorrhage in this disease is rare. 

Pain is not a constant accompaniment of cancer of 
the cervix in the early stages, nor is it in any way cha- 
racteristic. The intensity and character of the pain may 
depend upon the direction of the growth of the disease. 
In some cases pain is absent throughout. The pain may 
be dull and gnawing in character, or it may be sharp and 
lancinating. The pain may resemble that of uterine 
colic. It may be referred to the back in the region of 
the sacrum, or to one or both ovarian regions, or to some 
part of the pelvis remote from the uterus, as the crest or 
the anterior superior spine of the ilium. It may extend 
down the posterior or anterior aspects of the thighs or 
into the rectum. In most cases of cancer of the cervix 
pain is not a prominent symptom until the later stages. 

Discharge from the vagina may be present in cancer of 
the cervix before there are any symptoms of hemorrhage 
or pain. The discharge depends upon the position and 
character of the growth and the stage of the disease. It 
may first appear as an ordinary cervical leucorrhea in a 
woman previously free from such discharge; or the dis- 
charge of cancer may first appear as an increase of an 
accustomed leucorrhea. In such cases it is due to hyper- 
secretion from the irritated cervical glands. 

Later in the disease, when ulceration takes place or 
when the friable vascular vegetations appear, the leucor- 
rhea becomes puriform in character and streaked with 
blood. It then becomes thinner, less mucous in consist- 
ency, and of a constant brownish color from the admix- 
ture of blood. The pus and debris from the breaking- 
down cancerous mass increase, and a horrible odor 
characteristic of the later stages of cancer of the cervix 
appears. This odor is not peculiar to cancer. It is 
caused By the sloughing tissue, and is observed when 
such a process occurs in other conditions, as in sloughing 
fibroid polyp. The discharge is irritating in character, 
and the ostium vaginae, the vulva, and the inner aspects 



192 A TEXT-BOOK OF DISEASES OF WOMEN. 

of the thighs become excoriated in those who do not ob- 
serve strict cleanliness. 

Systemic absorption of the cancerous discharges pro- 
duces a general septic condition, which, with the anemia 
from hemorrhage and the uremia from obstruction of the 
ureters, results in the so-called cancerous cachexia. 

The symptoms that have just been described are those 
most usual in cases of cancer. It must always be re- 
membered, however, that these symptoms vary very much 
in intensity or prominence and in the stage of the disease 
at which they appear. Sometimes acute pain, hemor- 
rhage, and excessive discharge are present from the very 
beginning — even before the presence of cancer can be 
demonstrated without the aid of the microscope. In 
other cases all these symptoms may be absent until the 
disease is very far advanced. None of the symptoms are 
absolutely pathognomonic of cancer. During the men- 
strual life of the woman hemorrhage from the womb 
occurs as a symptom of a great variety of diseases; and 
even in the post-climacteric period, though hemorrhage 
should always excite alarm, yet it may be caused by a be- 
nign form of endometritis or intra-uterine growth. The 
pain of cancer may also characterize a variety of benign 
conditions; and the vaginal discharge, even when most 
offensive, may be simulated by that from a sloughing 
intra-uterine fibroid. 

The symptoms, however slight, which we know may 
occur with cancer of the cervix should never be dis- 
regarded. Examination should be made immediately. 
There should be no postponement or expectant plan of 
treatment. If physical examination is not satisfactory in 
elucidating the condition, resort should be had to the 
microscope. If this is not conclusive, the case should be 
watched as long as the suspicious symptoms continue, and 
further frequent examinations should be made. 

If this plan of treatment is followed, and if women are 
taught to view with distrust, and not with complacency, 
any irregularities of menstruation occurring near the time 



CANCER OF THE CERVIX UTERI. 193 

of the menopause, or any post-climacteric return of men- 
struation or of irregular bleeding, the surgeon will be 
able to save many women with cancer of the womb who 
are now doomed to horrible deaths. 

Cancer of the cervix, like cancer in other parts of the 
body, is of variable duration. Usually from one to three 
years elapse between the time when the first symptoms 
of the disease appear and the time of death. The dis- 
ease may run its course, in exceptional cases, in a few 
weeks; in other cases it may last as long as five years, 
especially if the progress is delayed by palliative treat- 
ment. 

Treatment. — Complete removal of the uterus is the 
only curative treatment for cancer of the cervix. If the 
disease is seen in the earliest stages, amputation of the 
cervix beyond the limits of the growth seems, theoreti- 
cally at least, to be a proper plan of treatment. Prac- 
tically, however, the operator can never be certain that 
the excision is made in healthy tissue. The senses of 
touch and unaided sight are not capable of defining the 
limits of malignant infiltration. Moreover, it must be 
remembered that the endometrium is very often involved 
secondarily from a cancerous focus in the cervix. Com- 
plete removal of the uterus should therefore always be 
practised in all cases in which there is a possibility of 
removing all of the disease. 

The manner of performing this operation will be 
described subsequently. 

The cases that are not suitable for the operation of 
hysterectomy are those in which the disease has extended 
to structures that are surgically inaccessible. Such cases 
include those in which the bladder or the rectum are in- 
volved, those in which the vagina is extensively impli- 
cated, and those in which the disease has extended into 
the broad ligaments or the cellular tissue of the pelvis. 

When the bladder is involved, there are dysuria, vesical 
pain, and tenderness on vaginal pressure upon the base 
of the bladder, while the urine is altered in character, 

13 



194 A TEXT-BOOK OF DISEASES OF WOMEN. 

containing blood, pus, and, in the later stages, broken- 
down necrotic tissue. Involvement of the rectum is 
manifest by digital examination. 

When the broad ligaments are involved the uterus is 
held rigidly in the pelvis or is drawn to one side, and the 
bases of the broad ligaments, palpated through the lateral 
vaginal fornices, are thick and hard. When the cellular 
tissue of the pelvis is generally involved the whole vag- 
inal vault feels indurated and the uterus seems fixed in 
the unyielding matrix. 

In examining with the view of determining the prac- 
ticability of hysterectomy, it is important to distinguish 
between cancerous and simple inflammatory involvement 
of the broad ligaments. The uterus may be fixed in the 
pelvis by inflammatory adhesions resulting from old tubal 
disease, and yet the cancer of the cervix may be strictly 
local and in a stage suitable for hysterectomy. In the 
simple inflammatory cases the adhesions are more atten- 
uated, are higher in the pelvis, and lie chiefly posterior to 
the uterus. They are not directly continuous with the 
cervix. Frequently the enlarged tube and the adherent 
ovary may be felt. When the uterus is fixed by cancer- 
ous involvement of the broad ligament, we readily feel 
that it is the base of the broad ligament that is involved. 
The induration is broad, it is directly continuous with 
the induration of the cervix, and it lies to the side of the 
uterus. 

Involvement of the pelvic lymphatic glands may some- 
times be determined by vaginal palpation, one or more 
such enlarged indurated glands being felt lying posterior 
to the uterus. In most cases, however, glandular in- 
volvement can be determined only after the abdomen has 
been opened. 

In general, it may be said that the operation of hyster- 
ectomy should be performed in all cases in which there 
is no cancerous involvement of the bladder and rectum, 
in which the vaginal disease may all be removed, and in 
which the uterus is freely movable. 



CANCER OF THE CERVIX UTERI. 195 

In those cases in which complete removal of the dis- 
ease is impossible the operation of hysterectomy should 
not be performed, because, cure being out of the ques- 
tion, the symptoms of hemorrhage, pain, and discharge 
may be as well relieved by less dangerous forms of pallia- 
tive treatment. When the disease extends beyond the 
limits of the uterus, hysterectomy is much more difficult 
and dangerous than when the uterus is freely movable. 

The remote results of hysterectomy for cancer of the 
cervix are poor. In the very great majority of all cases 
submitted to operation recurrence has taken place. It 
seems very probable that a few of the cases of recurrence 
are due to transplantation of cancer-cells into healthy 
tissue during the operation; but the vast majority die 
because all of the diseased tissues have not been or can 
not be removed. The hope for better results from the 
surgical treatment of cancer of the cervix depends, not 
upon improvement in the surgical technique, but upon 
the ability of the general practitioner to recognize the 
disease in its earliest stages, before inaccessible structures 
have been involved. 

Palliative Treatment of Cancer of the Cervix. — The 
palliative treatment consists in removing as thoroughly 
as possible, with the sharp spoon-curette, scissors, or 
knife, all the cancerous cervix, and the maintenance of 
the surfaces thus exposed, as far as possible, free from 
septic infection. 

The woman should be placed in the lithotomy position ; 
the cervix should be exposed with the Sims speculum 
and, if necessary, with the lateral vaginal retractors. 
All vegetations and all of the degenerated cervix should 
then be cut away. It is usually necessary to carry the 
excision of tissue as high as the internal os. Bleeding 
during this procedure is sometimes very profuse. It 
diminishes, however, as the more degenerated portions of 
the cervix are cut away and the healthier uterine tissue 
is reached, and therefore it is always best to complete the 
operation, notwithstanding hemorrhage. 



196 A TEXT-BOOK OF DISEASES OF WOMEN. 

The bleeding may be controlled by packing the cavity 
with gauze or cotton, plain or saturated with Monsel's 
solution. Moderate bleeding may be checked by packing 
with cotton saturated with a 5 per cent, solution of anti- 
pyrine. 

In rare cases, in which the excision of tissue has been 
carried high up in the lateral vaginal fornices, it may be 
necessary to ligate the uterine arteries in order to control 
the hemorrhage. This may be done by passing around 
the vessel, close to the cervix, a curved needle carrying 
a heavy ligature. Bleeding from the circular artery may 
readily be controlled in a similar way, the ligature being 
passed like the first suture in trachelorrhaphy. 

If the operation has been thoroughly performed, there 
will be left a large crater or conical cavity in the vaginal 
vault. This cavity may then be packed with sterile 
gauze, or, if there is much bleeding, with gauze saturated 
with Monsel's solution. Some surgeons sew together the 
walls of the cavity to diminish as much as possible the 
raw surface. Others char the walls with the actual 
cautery, in order to carry the destruction of tissue still 
farther than has been done with the knife. If the re- 
moval with the curette and knife has been thorough, it is 
not necessary to make a caustic application. If, how- 
ever, the cavity is walled by obviously cancerous tissue, 
the use of the caustic is advisable. This is usually the 
case. 

Chloride of zinc is a valuable caustic in cancer of the 
cervix. It should be applied as follows: After the can- 
cerous tissue has been removed as thoroughly as possible 
with the knife, the scissors, and the curette, bleeding 
from the walls of the cavity should be checked by pack- 
ing with gauze, dry or saturated with a 5 per cent, solu- 
tion of antipyrine. The bleeding may very often be 
checked in this way in a few minutes, and in this case 
the caustic may be immediately applied. In case, how- 
ever, the bleeding is not so quickly controlled, the pack- 
ing must be left in the cavity for twenty-four hours, at 



CANCER OF THE CERVIX UTERI. 197 

the end of which time it may be removed, without anes- 
thesia, and the caustic application may be made. 

Before introducing the caustic the vagina and the vulva 
should be protected by thorough greasing with an oint- 
ment composed of 1 part of bicarbonate of soda to 3 
parts of vaseline. 

The strength of the caustic should depend somewhat 
upon the thickness of the tissue that separates the cavity 
from the peritoneum or other important structures. The 
thickness may be approximately determined by palpation. 
Usually a 100 per cent, solution of chloride of zinc may 
be safely employed. If the walls of the cavity appear 
very thin — less than a quarter of an inch — the caustic 
may be reduced to a 50 per cent, solution. Small balls 
of cotton, about half an inch in diameter, should be 
saturated with the caustic and carefully packed in the 
cavity. The operator should be careful to remove quickly 
with the sponge any excess of caustic that may be ex- 
pressed from the cotton. Much unnecessary pain may be 
experienced if the caustic comes in contact with the va- 
gina or the vulva. 

When the cavity has been filled with the cotton balls 
carrying the chloride of zinc, a large vaginal tampon of 
cotton well greased with the alkaline ointment should be 
placed in the vaginal vault. The packing should be re- 
moved from the vagina in forty-eight hours, and vaginal 
douches of bichloride of mercury, 1 : 4000, should be ad- 
ministered. 

If this operation is carefully performed, the subsequent 
pain is usually slight. In some cases, however, the 
action of the caustic may be so painful that morphine is 
required. 

The slough from the caustic may be discharged in one 
piece or in shreds. It is usually separated in from five 
to ten days. 

The subsequent treatment of the woman consists in the 
frequent use of cleansing vaginal douches, such as a solu- 
tion of bichloride of mercury (1 : 4000), carbolic acid (3 



198 A TEXT-BOOK OF DISEASES OF WOMEN. 

per cent, solution), permanganate of potash (10 grains to 
the ounce of water), and peroxide of hydrogen (1 part of 
the commercial peroxide to 3 or 4 parts of water). 

The palliative treatment of cancer relieves the pain, 
the hemorrhage, and the discharge. The relief is usually 
immediate, and may continue throughout the disease. 
The hemorrhage is usually arrested for several weeks, or 
even for months, and the discharge is much diminished 
with the destruction of the necrotic cancerous mass. 
The progress of the disease is delayed, and life is some- 
what prolonged. 



CHAPTER XVII. 
DISEASES OF THE BODY OF THE UTERUS. 

ACUTE CORPOREAL ENDOMETRITIS. 

Acute inflammation of the mucous membrane of the 
body of the uterus is called acute corporeal endometritis. 
The disease is usually the result of septic infection occur- 
ring at a labor or a miscarriage. Occasionally acute 
gonorrheal endometritis is seen, but this disease usually 
produces an inflammation of the mucous membrane of the 
cervix and the body of the uterus that is chronic or sub- 
acute from the beginning. Septic infection through 
operative traumatism, through the use of the uterine 
sound, or through other gynecological methods of exam- 
ination may, of course, result in acute endometritis. 

The pathological changes that take place in an endo- 
metrium that is the seat of acute inflammation resemble 
those seen in acute inflammation of mucous membranes 
of other parts of the body. The secretion of the utricular 
glands becomes much increased in quantity and altered 
in character, becoming purulent and sometimes contain- 
ing blood. 

As would be expected, whenever the inflammation is at 
all severe the middle or muscular coat of the uterus 
is involved by the process; in other words, a metritis 
follows and accompanies the endometritis. In puerperal 
metritis abscesses varying in size from a pin-head to that 
of a hen's egg are sometimes found in the uterine wall. 

The septic infection may extend through the muscular 
wall of the uterus and involve the peritoneal covering, 
producing in this way a perimetritis. 

Acute inflammation of the endometrium sometimes 
occurs during the course of the exanthemata. The 

199 



200 A TEXT-BOOK OF DISEASES OF WOMEN. 

changes that take place in the mucous membrane of the 
uterus are similar to those seen in other mucous membranes 
during the course of these diseases. The local condition 
is usually limited by the duration of the general disease. 

It is probable that some of the cases of arrested de- 
velopment of the internal organs of generation, and cases 
of chronic tubal and ovarian disease seen in later life, 
may be traced to this exanthematous form of endometritis 
occurring during girlhood. 

The symptoms of acute endometritis vary very much 
in severity. Dull pain in the region of the uterus, 
referred to the supra-pubic region and the sacrum, is 
usually present. Reflex disturbance of the bladder, cha- 
racterized by frequent and often painful urination, may 
be present; and it is very probable that mild cases of 
endometritis have been diagnosed and treated as light 
attacks of cystitis. The temperature in the puerperal 
cases may be very high. The discharge from the cervix 
is very much increased, is puriform in character, and is 
occasionally streaked with blood. 

Digital examination shows that the external os is patu- 
lous, the cervix enlarged and soft, and the body of the 
uterus somewhat enlarged and tender upon pressure. 
This tenderness may be elicited by pressing the fundus 
between the vaginal finger in the anterior vaginal fornix 
and the abdominal hand. Examination through the 
speculum shows the discharge escaping from the exter- 
nal os. In case the cervical mucous membrane is also 
involved, a red area of erosion will be seen surrounding 
the os. 

Acute endometritis of non-puerperal origin is best 
treated by rest in bed, vaginal douches of hot boric- 
acid solution (3j to a pint of water) or of bichloride of 
mercury (i : 4000) at a temperature of ioo° to no°, and 
the continuous use of saline purgatives. Active intra- 
uterine treatment in these cases is not necessary. 
When, however, the disease occurs, as it usually does, 
from septic infection at a miscarriage or a labor, more 



DISEASES OF THE BODY OF THE UTERUS. 201 

radical treatment must be used. This treatment com- 
prises frequently-repeated intra-uterine douches, thorough 
curetting of the uterus, and, finally, hysterectomy in 
extreme cases. 

Every case of 'acute endometritis should be carefully 
watched and treated until the disease is cured. Acute 
endometritis, especially if gonorrhea is the cause, is very 
prone to become chronic and to extend to the mucous 
membrane of the Fallopian tubes and the ovaries. 

CHRONIC CORPOREAL ENDOMETRITIS. 

Chronic inflammation of the endometrium, or chronic 
endometritis, is much more frequently seen in practice 
than the acute form. It may occur as a primary dis- 
ease, but it very often occurs as the result of some other 
pathological condition of the uterus, as, for instance, sub- 
involution or uterine fibroid. 

A variety of confusing terms have been used to desig- 
nate the different forms of endometritis. There seem to 
be two chief forms of the disease: I. Chronic interstitial 
endometritis; II. Chronic glandular endometritis. 

In the first form of the disease the interglandular tissue 
is chiefly involved. The spaces between the glands are 
infiltrated with connective-tissue cells. 

In the second or glandular form of endometritis the 
disease affects the glandular apparatus. The utricular 
glands become much elongated, branched, and increased 
in number. The accompanying illustrations (Figs. 117, 
118) show the microscopic appearance of interstitial en- 
dometritis and glandular endometritis. 

These two forms of endometritis are often mixed, and 
the same uterus may present the glandular form of in- 
flammation upon part of the endometrium, the intersti- 
tial form upon another part, and the mixed form upon 
still another part. 

The gross appearance of the endometrium varies with 
the form of the disease and its duration. It will be re- 
membered that in the mature uterus, in the menstrual 






a\ 



Fig. 117. — Interstitial endometritis: microscopic section of endometrium 
removed by the curette (Beyea). 




.p. 



Fig. 118. — Glandular endometritis: microscopic section of endometrium 
removed by the curette (Beyea). 



V. XX- 






J? *S fit-!"" 






D 



Fig. 119. — Polypoid endometritis (Beyea). 



DISEASES OF THE BODY OF THE UTERUS. 203 

interval, the mucous membrane is a thin reddish-gray 
structure about 1 millimeter (-^5- inch) in thickness. In 
the different forms of endometritis the mucous membrane 
may become hypertrophied to three or four times this 
thickness. In some unusual cases the mucous membrane 
may become even still further hypertrophied, attaining 
a thickness of half an inch. A special name, fungous 
endometritis, has been given to the disease when it as- 
sumes this form. Microscopic examination shows that 
fungous endometritis is merely a mixed form of the 
glandular and the interstitial varieties, with a great in- 
crease of all the elements of the mucous membrane. In 
fungous endometritis the hypertrophy of the mucous 
membrane may be uniform throughout the body of the 
uterus or it may occur only in localized areas. 

In some cases the glandular hypertrophy of the mucous 
membrane assumes the form of polypoid growths project- 
ing into the uterine cavity (Fig. 119). 

In the advanced stages of all the forms of endometritis 
cicatricial formation takes place. The normal ciliated 
epithelium of the endometrium is cast off, and is replaced 
by flat squamous cells. The glands atrophy; the glandu- 
lar openings become dilated, and ultimately appear as 
simple depressions on the surface. In time secretion 
from the glands ceases, and the cavity of the uterus be- 
comes lined with simple connective tissue. 

Chronic endometritis is always accompanied to a greater 
or less extent by inflammation of the muscular coat of 
the uterus. The pathological changes that take place re- 
semble those occurring in chronic inflammation in similar 
musculo-fibrous structures in other parts of the body. 
A section of the uterine wall is much lighter in appear- 
ance than normal, and the whitish bundles of connective 
tissue are seen interlacing with the more vascular muscu- 
lar fibers. 

At first there is an hypertrophy of the uterine wall 
from infiltration of inflammatory material. In the latest 
stages organized connective tissue is formed, and there is 



204 A TEXT-BOOK OF DISEASES OF WOMEN. 

produced a sclerotic condition of the uterus, with atrophy 
of its normal muscular elements. 

The hypertrophy of the uterus, however, that accom- 
panies most of the forms of endometritis is not due alto- 
gether to the presence of inflammatory deposits. The 
uterus possesses the peculiar property of enlarging, by 
a general hypertrophy of its elements, whenever there is 
present in its cavity any gross pathological condition. 
We see this in fibroid tumor. And, as a general rule, 
the enlargement is proportional to the mensurable size 
of the disease. 

The metritis may involve the whole of the uterine 
body, or it may occur in localized areas. It may affect 
only the body of the uterus, or the body and the cervix, 
or, as we have already seen, the cervix alone. When the 
disease is localized to part of the uterine wall, the indu- 
ration of the affected area may sometimes be determined 
by palpation. 

Symptoms. — The symptoms of chronic endometritis 
are often obscured by symptoms that are to be referred 
to other accompanying conditions. For instance, the 
endometritis very often accompanies subinvolution of 
the uterus, laceration of the cervix, uterine displace- 
ment, or ovarian and tubal disease. Cases of simple 
uncomplicated endometritis are the exception. 

The menstrual function is usually affected. The period 
is of longer duration, the loss of blood is greater, and 
the periods may occur more frequently than normal; in 
other words, there is present menorrhagia. In this dis- 
ease bleeding also occasionally occurs between the men- 
strual periods. Hemorrhage is a symptom that is most 
prominent in cases of interstitial and fungoid endo- 
metritis. 

The secretion of the utricular glands is also increased 
in amount. This symptom is most pronounced in cases 
of glandular endometritis. The secretion is thin and 
purulent in character, and is often streaked with blood. 
It decomposes very readily, and consequently is often 



DISEASES OF THE BODY OF THE UTERUS. 205 

offensive and excites the suspicion of malignant dis- 
ease. 

The character of the typical discharge from the body 
of the uterus is usually obscured by admixture with dis- 
charge from the cervical mucous membrane. Cervical 
catarrh, or inflammation of the cervical mucous mem- 
brane, may,, and usually does, occur alone, without in- 
volvement of the upper endometrium, but chronic cor- 
poreal endometritis is usually associated with inflamma- 
tion of the cervix. If the discharge is observed at the 
vulva, it will be still further altered by admixture with 
the vaginal secretion. The discharge from the corporeal 
endometrium is thinner and more serous than the mucus 
of the cervical canal, and is more usually purulent and 
streaked with blood. 

The discharge from the endometrium is very often in- 
creased very decidedly immediately before and after the 
menstrual period. 

Pain is a general symptom of chronic endometritis. 
The pain is uterine in character, and is referred to the 
lower abdomen and the back. There is also very con- 
stantly present reflex headache localized on the top of 
the head or in the occiput. 

The pain may be present at all times, but it is usually 
most marked when the woman is upon her feet and the 
pelvic congestion is increased. The pain is always great- 
est immediately before and during the menstrual period. 

General physical weakness and debility are often very 
pronounced, and seem to be out of proportion to the 
extent of the local disease. This same phenomenon has 
been spoken of in the consideration of uterine displace- 
ments. The weak and aching back, the dragging sensa- 
tions in the pelvis, the tired legs, may all appear after 
the woman has been upon her feet but a short time, and 
utterly incapacitate her for any kind of labor. 

Nervousness, neurasthenia, hysteria, and mental de- 
pression and melancholia are apt to occur in this disease. 
Such nervous phenomena are common to all diseases of 



206 A TEXT-BOOK OF DISEASES OF WOMEN. 

the uterus. The mental depression is often very marked, 
and is exaggerated before and during each menstrual 
period. 

The woman with chronic endometritis is usually 
sterile; or if she becomes pregnant, abortion will prob- 
ably occur. The discharges in the uterine cavity are 
inimical to the spermatozoa, and the diseased endo- 
metrium furnishes an inefficient place for the attachment 
of the ovum. 

Physical examination in a simple case of chronic endo- 
metritis shows a somewhat enlarged uterus, more globu- 
lar in shape than normal. The fundus uteri is tender 
on pressure between the vaginal finger and the abdominal 
hand. The external os is usually patulous. 

Examination with the speculum shows the discharge 
escaping from the external os. If there is also present 
cervical endometritis, the discharge presents the charac- 
teristics of both cervical and corporeal mucus. It is 
thick and tenacious, puriform, and often streaked with 
blood. After the cervical canal has been wiped out the 
characteristic corporeal discharge may appear unmixed 
with cervical mucus. This discharge is thin, purulent, 
and may be streaked with blood, or it may be brownish 
in color from mixture with altered blood. 

If the uterus is examined with the uterine sound, it 
will be found that the internal os is patulous; the fundus 
is decidedly tender upon gentle pressure with the sound, 
and even the gentlest use of the sound may be followed 
by bleeding. 

The patulous condition of the cervical canal and the 
internal os is a constant characteristic of all kinds of 
gross disease in the cavity of the uterus. The external os. 
is usually patulous when the cervical mucous membrane 
is diseased. The external os, the cervical canal, and the 
internal os are open when the corporeal endometrium is 
diseased. 

The only certain method of making the diagnosis is 
by the use of the sharp uterine curette, and this instru- 



DISEASES OF THE BODY OF THE UTERUS. 207 

ment should always be employed whenever there is even 
the slightest suspicion of the possibility of malignant dis- 
ease of the endometrium. The cervical canal is usually 
sufficiently open to permit the use of the curette without 
dilatation and without an anesthetic. Three or four strips 
of the endometrium should be removed from different 
parts of the uterine cavity, and should be submitted to 
microscopic examination. It is always safest to perform 
curetting for diagnosis at the house of the patient, and to 
keep her in bed for two or three days after the operation. 
Strict antisepsis should be observed. 

The causes of chronic corporeal endometritis are vari- 
ous. Almost any disease of the body of the uterus or of 
the cervix may eventually result in this condition; there- 
fore the different causes of chronic endometritis will be 
better appreciated after a discussion of diseases of the 
uterus. Laceration of the cervix, subinvolution, flexions 
and versions, fibroid tumors, etc., all produce, in time, 
some form of chronic endometritis. 

Primary chronic endometritis may result as a later 
stage of the acute disease, or it may exist from the be- 
ginning in the chronic form. This is especially true 
of endometritis caused by gonorrhea. Here the inva- 
sion of the disease is slow and insidious, and in the 
majority of cases is preceded by no determinable acute 
stage. 

Sometimes endometritis appears in old women. Bleed- 
ing from the uterus, purulent discharge, and pain may be 
present. The condition is due to the atrophic changes 
of senility occurring in the endometrium — changes that 
resemble those that take place in the mucous membrane 
of the vagina and the external genitals. Though such 
symptoms may be indicative merely of a benign condi- 
tion, yet, as they are also characteristic of the early stages 
of malignant disease, they demand immediate thorough 
examination and careful watching. 

Treatment. — As chronic endometritis is usually sec- 
ondary to some disease of the cervix or body of the ute- 



2o8 A TEXT-BOOK OF DISEASES OF WOMEN. 

rus, the treatment should be directed toward the cure of 
this primary condition. 

The operation of trachelorrhaphy will cure the subin- 
volution of the uterus and the resulting endometritis. 
Forcible dilatation of the cervix, in the case of an old 
anteflexion, will relieve the inflammation of the endo- 
metrium. Correction of a retroversion will likewise re- 
lieve the resulting endometritis. Therefore, though in 
every case the cure may be hastened by treatment applied 
directly to the endometrium, yet causative or complicat- 
ing conditions must always also be treated if we wish the 
cure to be lasting. 

Many cases of mild endometritis may be relieved or 
cured by attention to the general hygiene and habits of 
the woman and by applications made only to the vaginal 
aspect of the uterus. The dresses should be worn loose 
about the waist and supported from the shoulders. Pro- 
longed standing and slow walking should be avoided. 
Mild purgation with salines should be maintained. Reg- 
ulated exercise or general massage should be prescribed. 
In addition, the vaginal douche, iodine applications, and 
the use of the glycerin tampon, with depletion from 
puncture of the cervix, should be used, as has already 
been prescribed for the subinvolution accompanying 
laceration of the cervix. 

If these methods fail after careful trial, direct treat- 
ment must be applied to the endometrium. 

The present method of treating chronic corporeal endo- 
metritis directly is by the uterine curette. Time is wasted 
by the use of applications to the interior of the uterus, 
and a great deal of harm has resulted from such appli- 
cations carelessly made. 

The best curette is the Sims sharp curette (Fig. 120). 
The Martin curette (Fig. 121) is useful to remove the 
endometrium from the fundus. 

The operation had best be performed in the menstrual 
interval, though it may safely be performed during the 
menstrual period. An anesthetic should always be ad- 



DISEASES OF THE BODY OF THE UTERUS. 209 

ministered. The woman should be placed in the dorso- 
sacral position, with the feet in the supports. The vulva, 



r^ 






Fig. 120. — Sims's sharp curette. 



vagina, vaginal cervix, and buttocks should be thor- 
oughly sterilized. 

The anterior lip of the cervix should be grasped with a 




Fig. 121. — Martin's curette. 

double tenaculum. The cervical canal should be wiped 
out with a small sponge or with cotton and irrigated with 
bichloride, if the external os is sufficiently patulous. 
The cervical canal and the internal os should then be 
dilated to about one inch. The position of the uterus 
should have been previously determined by careful bi- 
manual palpation. 

The Sims curette should be gently introduced to one 
cornu and then drawn methodically over the whole of 
the uterine surface, removing the endometrium in parallel 
strips, the length of each strip being equal to the distance 
between the internal os and the fundus. The curette 
may be withdrawn from the uterus and washed in dis- 
tilled water as each strip is removed, or withdrawal and 
washing may be done after two or three strips have been 
removed. The Martin curette should then be introduced 
to one cornu and scraped over the fundus, as there is usu- 
ally in this situation a narrow strip of endometrium that 
is not removed by the Sims curette. 

The uterus should then be washed out with warm 
sterile water or with a 1 : 4000 bichloride solution. The 
washing may be done by holding the cervical canal open 
with the small dilator and introducing the loner tubular 
syringe nozzle, or by some form of reflux tube (Fig. 122). 

14 



2IO A TEXT-BOOK OF DISEASES OF WOMEN. 

Opportunity must always be afforded for the escape of the 
irrigating fluid. 

The operator should always remember the danger of 
perforating the uterus by the curette. This accident, 
which has happened in the hands of the best surgeons, 
occurs usually as the instrument is introduced, not as it 
is withdrawn. It is much more liable to occur after labor 




Fig. 122. — Irrigation of the uterus. 

or recent abortion, when the uterine tissues are soft, than 
in the conditions now under consideration. If perforation 
should happen, the uterus should be carefully washed out 
with the bichloride solution, the vagina should be lightly 
packed with gauze, and the patient returned to bed. A 
hypodermic injection of ergotin should be administered, 
and afterward, when the woman recovers from the an- 
esthetic, small repeated doses of fluid extract of ergot 
should be administered to ensure uterine contraction. If 
the operation has been performed aseptically, it is prob- 
able that no harm will result from the accident. If peri- 
tonitis should develop, celiotomy must immediately be 
performed. 

After curetting the uterus some operators are in the 
habit of packing the uterine cavity with sterile or iodo- 
form gauze. This procedure is liable to obstruct the 
escape, rather than favor the drainage, of any discharges 
from the cavity of the uterus. Elevation of temperature 
and uterine pain are often caused by it; therefore it is 
best, after the operation of curetting, merely to pack the 
vagina lightly with sterile gauze, which should be re- 
moved in forty-eight hours. Daily douches of a i : 4000 



DISEASES OF THE BODY OF THE UTERUS. 2ii 

bichloride-of-mercury solution should then be adminis- 
tered as long as the woman remains in bed. The vagina 
should be carefully dried after the douche, as already 
advised. 

Hemorrhage is never profuse during curetting, and 
usually ceases after the endometrium has been removed 
and the uterus has been washed out. 

In cases of gonorrheal endometritis it is advisable, 
after the uterus has been douched and the bleeding has 
ceased, to apply carbolic acid thoroughly over the whole 



I I ?/ \ I 1 J \\ /I ;, i i\ 1 1 I 

/i /i \\ \\ 1 1 \\ \ i v'-'l 



oi 



Fig. 123. — Microscopic section of the normal endometrium, showing the utricu- 
lar glands extending into the muscular tissue (Beyea). 

interior of the uterus, because infection may lurk in the 
distal ends of the utricular glands, which are not removed 
by the curette. 

The length of time during which it is advisable to keep 
the woman in bed depends upon the extent and nature 
of the disease for which the curetting has been done. 
As a general rule, the longer the stay in bed the better 
it is for the woman. If the uterus is much enlarged or 
if subinvolution is present, the patient should stav in bed 
for two weeks. Such rest in the recumbent position 



212 A TEXT-BOOK OF DISEASES OF WOMEN. 

diminishes the congestion of the pelvic organs and is of 
great aid in restoring the parts to a normal condition. 
Careful attention should be paid to the regularity of the 
bowels. Mild purgation with saline purgatives should be 
continued during the convalescence. Daily massage, 
started two or three days after the operation, will facili- 
tate the cure. 

All the endometritial structures are never completely 
removed by the curette. The distal ends of the utricular 
glands, which penetrate the muscular coat of the uterus 
(see Fig. 123), remain after thorough and vigorous curet- 
ting. 

After removing the endometrium with the curette the 
cavity of the uterus does not become lined with a cica- 
tricial membrane, but a new endometrium is produced. 
It is probable that the new membrane is developed from 
the remains of the utricular glands. The new endo- 
metrium grows in a very short time. In some cases it 
has been sufficiently well formed to permit pregnancy 
five weeks after curetting. 

The first menstrual period, and sometimes the second 
and third, after the operation of curetting may be missed. 
As a general rule, the menstrual bleeding is much less 
profuse than before the operation. 

The therapeutic object of curetting for endometritis is 
to replace the diseased endometrium by a new membrane 
which has grown under conditions of rest and asepsis. 

EXFOLIATIVE ENDOMETRITIS, OR MEMBRANOUS DYS= 
MENORRHEA. 

There is a disease which has been called membranous 
dysmenorrhea or exfoliative endometritis, in which large 
membranous pieces of the endometrium or a cast of the 
whole structure is thrown off at the menstrual period 
(see Fig. 124). The condition is most often found in vir- 
gins or sterile women. The membrane may be thrown 
off at every menstrual period, or at periods separated by 
intervals of various length. 



DISEASES OF THE BODY OF THE UTERUS. 213 




Fig. 124. — Membrane dis- 
charged in membranous dys- 
menorrhea. 



The menstrual period is usually accompanied by intense 
uterine pain, which may resemble labor-pain, and which 
persists until the separation of 
the endometrium. In some cases 
of this disease menstruation is 
very irregular. 

The diagnosis is made from ex- 
amination of the characteristic 
membrane that is discharged. 
The condition should not be 
confused with abortion, in which 
the large irregular decidual cells 
will be discovered. Some wo- 
men are very liable to early 
menstrual miscarriage, and have 
repeated accidents of this kind, 
which in some cases have led the 
physician to believe that the condition of exfoliative endo- 
metritis was present. 

The local treatment consists of dilatation and curet- 
ting of the uterus, which operation it may be necessary 
to repeat several times. Careful attention should be di- 
rected toward re-establishing or maintaining the general 
health. 

SENILE ENDOMETRITIS. 

This disease, also called post-climacteric endometritis, 
occurs at any period after the menopause. There is a 
thin seropurulent discharge from the uterus, often so pro- 
fuse as to soil the clothing. The quantity of the dis- 
charge may be increased with a certain monthly period- 
icity. The discharge is often streaked with blood, or is 
brown colored from the presence of altered blood. There 
may be occasional or even continuous slight hemorrhage 
from the uterus. The discharge is usually fetid, and may 
be exceedingly irritating to the vagina and vulva. The 
objective symptoms often resemble in all respects the 
symptoms of cancer of the body of the uterus. 



214 A TEXT-BOOK OF DISEASES OF WOMEN. 

There is usually dull pain in the lower part of the 
abdomen and the back; and if the disease continues for 
sufficient time, there may appear symptoms indicative of 
septic absorption — loss of appetite, emaciation, and 
slight elevation of temperature. 

The pathologic changes which take place in the 
uterus in this disease have not been definitely determined. 
It seems probable that in some cases the condition may 
be produced, as in senile vaginitis, by infection of an 
endometrium the integrity of which had been impaired 
by the atrophic changes occurring after the menopause. 
Microscopic examination of portions of the endometrium 
removed by the curette shows the appearance of long- 
standing chronic inflammation. 

These cases are often mistaken for cancer of the body 
of the uterus, and the diagnosis should always be imme- 
diately made by microscopic examination of the material 
removed by a thorough curetting of the whole of the 
uterine cavity. 

The treatment of senile endometritis consists of appli- 
cations to the endometrium of a solution of nitrate of sil- 
ver, from one-half to one dram to the ounce of water, or 
of thorough curetting of the endometrium. 



CHAPTER XVIII. 

SUBINVOLUTION OF THE UTERUS; 5UPERINV0LU= 
TION OF THE UTERUS. 

SUBINVOLUTION OF THE UTERUS. 

Subinvolution of the uterus is a condition that results 
from imperfect involution of the uterus after labor, abor- 
tion, or miscarriage. The muscular and fibrous struc- 
tures of the uterus, which had become hypertrophied 
under the influence of pregnancy, fail to undergo prop- 
erly the retrograde changes of fatty degeneration and ab- 
sorption which normally occur after the expulsion of the 
product of conception, and which are essential for the 
restoration of the uterus to its normal size. The ele- 
ments of the endometrium and the vascular system of 
the uterus also remain hypertrophied; consequently the 
uterus is larger, heavier, more congested than normal. 

Similar arrest of involution may occur coincidently in 
the ligaments of the uterus, which are left larger, longer, 
and more relaxed than in the normal condition. 

The pathological changes that occur in the subinvo- 
luted uterus are similar to those found in chronic endo- 
metritis and metritis, which have already been described. 
In fact, chronic endometritis and metritis accompany 
subinvolution from the beginning. 

There are many causes of subinvolution of the uterus. 
Too early rising from bed is a most frequent cause. This 
is especially true after abortion or miscarriage; for many 
women treat such occurrences as of but little moment, 
and refuse to stay in bed for more than a few days. 

Imperfect evacuation of the uterus after abortion or 
miscarriage is a common cause. Laceration of the cervix, 

215 



216 A TEXT-BOOK OF DISEASES OF WOMEN. 

retrodisplacement of the uterus, and laceration of the 
perineum are all causes of subinvolution of the uterus. 

The symptoms of subinvolution are the same as those 
already described under Chronic Metritis — backache, 
headache, bearing-down pain in the pelvis, general phys- 
ical debility, leucorrhea, and menorrhagia. 

The treatment of subinvolution should be directed 
toward the relief of the primary cause of the condition. 
Laceration of the perineum or of the cervix, retroversion, 
or endometritis caused by retention of placental tissue 
after miscarriage, should receive appropriate treatment. 

Subinvolution may often be cured by the douches, 
iodine applications, and depletion of the cervix spoken 
of under the treatment of laceration of the cervix, pro- 
vided the primary cause is removed or corrected. 

In any case the cure is always hastened by thorough 
curetting of the uterus. This operation should always 
be performed when the woman is etherized for the relief 
of any other condition, as a laceration of the cervix or of 
the perineum. 

The cure of subinvolution depends a great deal upon 
the time that has elapsed from the inception of the con- 
dition to the institution of treatment. The secondary 
changes in the endometrium and body of the uterus 
resulting from chronic congestion and inflammation in 
time becomes so established that the disease will not 
yield to any treatment, even though the primary cause 
of the trouble may be cured. 

In obstinate chronic cases of subinvolution of the ute- 
rus amputation of the cervix sometimes has a most 
marked effect, and this operation should always be re- 
sorted to whenever the disease has resisted the milder 
treatment already prescribed. Amputation of the cervix 
is sometimes followed by a transformation of all the tis- 
sues of the uterus similar to that occurring in normal 
involution after labor, and a striking diminution in the 
size of the uterine body takes place. The amputation 
of the cervix should always be accompanied by a thor- 



SUPERINVOLUTION OF THE UTERUS. 217 

ough curetting. Sometimes the change in the body of 
the uterus is so marked after amputation of the cervix, 
or even after trachelorrhaphy, that a condition of super- 
involution, or uterine atrophy, results. 

SUPERINVOLUTION OF THE UTERUS. 

Superinvolution of the uterus is a disease the reverse 
of subinvolution. In this condition the uterus, after 
childbirth or abortion, not only undergoes the normal 
involution, but continues to atrophy until the length of 
the uterine cavity may measure but one and a half inches. 
The atrophy involves the neck as well as the body of the 
organ, the Fallopian tubes, and sometimes the ovaries. 

Superinvolution of the uterus is a rare condition. The 
cause is difficult to determine. It has been attributed to 
great loss of blood at confinement, to prolonged lactation, 
and to pelvic peritonitis occurring during the puerperium. 

Amenorrhea is the most marked symptom of superin- 
volution. Nervous disturbances and hysterical symptoms 
may also be present. 

The diagnosis is easily made from the history of the 
case and by means of bimanual examination and the use 
of the sound. Congenital malformation may be excluded 
from the fact that a pregnancy has occurred, and senile 
atrophy from a consideration of the age and history of 
the woman. The treatment should be directed to restor- 
ing and maintaining the general health of the woman. 

Iron and the remedies useful in other forms of amenor- 
rhea may be of advantage. 



CHAPTER XIX. 

CANCER AND SARCOMA OF THE UTERUS. 

CANCER OF THE BODY OF THE UTERUS. 

Cancer of the body of the uterus is a rare disease in 
comparison with cancer of the cervix. The older statis- 
tics — those of Schroeder — appear to show that the disease 
begins in the body of the uterus in about 2 per cent, of 







r 




Fig. 125. — Diffuse cancer of the endometrium. 

all cases of cancer of this organ. This percentage, how- 
ever, is probably too small. Cancer of the body of the 
uterus is by no means an infrequent disease ; it is a dis- 
ease for which the physician should always be on the 
watch. 

218 



CANCER AND SARCOMA OF THE UTERUS. 219 

Cancer of the body of the uterus originates in the epi- 
thelial structures of the endometrium. It may first ap- 
pear on the surface of the endometrium or deeply in the 
utricular glands. 

The gross appearance of the disease varies as does 
cancer of the cervix or of any other part of the body. 

Cancer of the uterus may begin upon the surface of 
the endometrium as a superficial ulceration, as a uniform 
swelling of the mucous membrane, as a polypoid or pap- 
illary projection, or as a large cauliflower-like mass pro- 
jecting into the uterine cavity. 

When the disease begins in the utricular glands, it may 
form nodules throughout the bodv of the uterus. These 




Fig. 126. — Nodular form of cancer of the body of the uterus. 

nodules are of various sizes, from that of a pea to that of 
a hen's egg. They grow rapidly. They may be sub- 
mucous and project into the uterine cavity, or they may 
project beneath the peritoneal covering, giving the uterus 
an irregular nodular appearance (Fig. 126). 

In the later stages of the disease the whole body of 
the uterus becomes infiltrated. The endometrium is 
destroyed. The cancerous masses ulcerate and break 
down. The peritoneal covering is for a certain time a 
barrier to the extension of the disease. In many cases 



220 A TEXT-BOOK OF DISEASES OF WOMEN. 

the whole of the body of the uterus may be infiltrated 
with cancer, and yet the peritoneum will remain intact. 
The accompanying illustration (Fig. 127) shows this: 
the infiltration extends to, but does not involve, the peri- 
toneum. 

Later, however, the peritoneum, the Fallopian tubes, 
and the ovaries become involved. Intestinal adhesions 




Fig. 127. — Cancer of the body of the uterus: a large single cancerous nodule 
(if) in the anterior wall has been divided. 

are formed, and the disease may extend throughout the 
abdominal cavity. The cervix and the vagina may be 
attacked by extension from above, though, on the other 
hand, the disease may progress sufficiently to destroy 
life, and yet the cervix may remain unaffected. 

Metastasis may take place by way of the lymphatics. 
Extension by metastasis, however, is unusual. 

Cancer of the body of the uterus occurs at a somewhat 
later age than cancer of the cervix. The average age is 
between fifty and sixty. The disease attacks both the 
parous and nulliparous woman, the latter perhaps more 
often than the former. 



CANCER AND SARCOMA OF THE UTERUS. 221 

The causes of cancer of the body of the uterus are 
unknown. It is probable that the various forms of endo- 
metritis, by diminishing the resistance of the endo- 
metrium, predispose to the development of cancer. It 
has been maintained that fibroid tumors of the uterus, as 
a result of the accompanying alterations in the endo- 
metrium, predispose to cancer. Cancer of the endo- 
metrium is certainly not infrequently found in uteri con- 
taining fibroid tumors. 




% - 






( ''\% 



Fig. 128. — Malignant adenoma of the body of the uterus (Beyea). 

Malignant adenoma is a disease of the utricular glands 
which has been classed by some writers as a distinct dis- 
ease, by others as a form of carcinoma. In it the gland- 
spaces are much enlarged, irregular, and joined to other 
gland-spaces. The columnar epithelial cells often fill 
the whole of the gland-space (Fig. 128) The cells, 



2 22 A TEXT-BOOK OF DISEASES OF WOMEN. 



however, never infiltrate the interstitial tissue, as in 
cancer. The muscular wall of the uterus appears to be 
destroyed by atrophy or by fatty degeneration. 

The disease is malignant, it extends to the neighboring 
structures, and it destroys life. It presents, in the later 
stages, all the gross appearances and phenomena of 
cancer. 

The symptoms of cancer of the fundus are hemor- 
rhage, leucorrheal discharge, and pain. 




Fig. 129. — Advanced malignant adenoma of the body of the uterus. A fibroid 
tumor (T) is in the fundus. 

In women before the time of the menopause the hemor- 
rhage may appear as a menorrhagia or a metrorrhagia, 
as an increase of the normal menstrual bleeding, or as a 
bleeding occurring at some other time than the normal 
menstrual period. Such irregular bleeding may be caused 
by any unusual effort. 

After the menopause the hemorrhage may appear as a 



CANCER AND SARCOMA OF THE UTERUS. 223 

return of menstruation, occurring with more or less 
periodicity, and, as in cancer of the cervix, often con- 
templated with satisfaction by the woman. It may ap- 
pear as a slight occasional discharge of blood, as a bloody 
streak in the leucorrheaj. discharge, as a spot upon the 
clothing, or as continuous hemorrhage. In the late 
stages of the disease there is a continuous discharge of 
blood. 

The leucorrheal discharge at first resembles that of a 
non-malignant endometritis. It often begins as a grad- 
ual increase of a leucorrhea which the woman may have 
had for several years. It may be streaked with blood. 
In the early stages there is nothing at all characteristic 
about the discharge; later, however, it usually becomes 
very offensive, on account of the breaking down of 
necrotic tissue. It becomes more purulent in character, 
and brown in color from the presence of blood. In some 
cases of cancer of the fundus, however, the leucorrheal 
discharge remains light-colored and practically odorless 
throughout the whole course of the disease. It is some- 
times thin and watery and exceedingly profuse, saturating 
many napkins during the day. 

The pain of cancer of the fundus is not a marked 
symptom. It may be absent even though the whole 
body of the uterus be involved by the disease. When 
the peritoneum is affected, and extension takes place to 
other pelvic structures, the pain is much more pro- 
nounced. In other cases the pain may be present in the 
early stages, before the disease has extended beyond the 
endometrium. 

The pain may be referred to the region of the uterus, 
to the back, or sometimes to parts of the pelvis remote 
from the uterus, as the crest of the ilium. 

Bimanual examination shows a patulous external os, 
cervical canal, and internal os. As has already been 
said, this patulous condition is characteristic of gross 
disease of the endometrium. 

The body of the uterus is usually somewhat enlarged, 



224 A TEXT-BOOK OF DISEASES OF WOMEN 

tender on pressure between the vaginal finger and the 
abdominal hand, and, in the late stages of the nodular 
form of cancer, irregular in outline. 

The causes of death in cancer of the fundus uteri are 
the same as those that have already been considered in 
cancer of the cervix. Extension to abdominal organs is, 
however, more frequent in cancer of the fundus. 

Diagnosis. — It is of the greatest importance to make 
an early diagnosis of cancer of the fundus uteri, because, 
of all parts of the body that may be attacked by malig- 
nant disease, the fundus uteri offers the best prospect of 
cure by operation. In the early stages the disease can 
easily be completely removed. 

Hemorrhage from the uterus is the universal symptom, 
and should never be disregarded. The various manifes- 
tations of hemorrhage in cancer of the fundus should 
always be borne in mind, and should always prompt a 
thorough investigation. 

Leucorrheal discharge occurring at or after the men- 
opause, in a woman previously free from such discharge, 
should also excite suspicion. 

If a careful examination of the cervix fails to reveal 
any cause for the hemorrhage or the discharge, the inte- 
rior of the uterus should be thoroughly examined by the 
curette. 

A patulous cervical canal and internal os are good indi- 
cations that there is some gross disease of the endome- 
trium. In cancer of the fundus the cervical canal and 
the internal os are usually sufficiently open to permit 
thorough curetting without further dilatation. 

The Sims sharp curette may be used with safety if 
ordinary care be observed. If the woman is nervous, an 
anesthetic should be administered, though in most cases 
diagnostic curetting gives but little pain and may be per- 
formed without ether. 

The operator should not be content with the removal 
of a few strips or portions of the endometrium. He 
should remember that in the early stages the disease may 
be confined to a small area, and, unless the whole interior 



CANCER AND SARCOMA OF THE UTERUS. 225 

of the uterus is gone over, this area may be missed by 
the curette, and only healthy endometrium may be re- 
moved for examination. Such thorough curetting is of 
especial importance in case the tissue removed should at 
first present no suspicious features upon gross examina- 
tion. All portions of the endometrium should be saved 
and preserved as directed in cancer of the cervix. 

The tissue should be submitted for examination to a 
person trained in gynecological pathology. The recog- 
nition of the early stages of cancer of the endometrium, 
and especially of malignant adenoma, requires the train- 
ing of the expert. If a positive diagnosis cannot be 
given from the microscopic examination, the case should 
be carefully watched, and if the symptoms continue, 
subsequent curetting and microscopic examination should 
be made. 

The treatment of cancer of the fundus is immediate 
complete hysterectomy, with removal of the tubes and 
ovaries. Cancer has recurred in an ovary after removal 
of the uterus. The hysterectomy may be performed by 
the vaginal, the abdominal, or the combined method. 

The ultimate results of hysterectomy for cancer of the 
body of the uterus are exceedingly good. Statistics show 
about 75 per cent, of permanent cures. Recurrence may 
be considered exceptional. In this respect they are in 
marked contrast to the results after operation for cancer 
of the cervix. 

SARCOMA OF THE UTERUS. 

Sarcoma of the uterus is a very rare disease. There 
have been but few properly authenticated cases of this 
disease reported in medical literature. All cases of this 
disease should be put on record. 

There are two varieties of sarcoma of the uterus: dif- 
fuse sarcoma of the mucous membrane, and sarcoma of 
the uterine parenchyma. 

In diffuse sarcoma of the mucous membrane the 

endometrium is infiltrated by round or spindle cells. 
15 



226 A TEXT-BOOK OF DISEASES OF WOMEN. 

Soft projections or tumors, which may be villous, lob- 
ulated, or polypoid in shape, are formed upon the mucous 
membrane. 

The polypoid sarcoma may present at the cervix uteri. 
The disease extends to the muscular coat of the uterus. 




Fig. 130. — Diffuse sarcoma of the mucous membrane of the uterus. 

In the later stages ulceration and disintegration of tis- 
sue occur. 

The cervix is not involved by the disease. 

The symptoms of this form of sarcoma resemble those 
of cancer of the fundus. There are hemorrhage, dis- 
charge, and pain. 

The discharge is serous, and is less fetid than in cancer, 
as ulceration takes place later in the course of the disease. 

The cervical canal is patulous, and in the polypoid 
form the tumor may be felt projecting into the cavity of 
the uterus or protruding from the external os. 

The fundus uteri is enlarged and is tender upon pres- 



CANCER AND SARCOMA OF THE UTERUS. 227 

sure. A positive diagnosis can be made only by micro- 
scopic examination of curetted or excised tissue. 

Sarcoma of the uterine parenchyma, or fibrosar- 
coma, or recurrent fibroid, begins in the muscular coat of 
the uterus. It appears as nodules of various size, which 
may be interstitial or confined to the muscular coat, sub- 
mucous or projecting beneath the mucous membrane, or 
subperitoneal, projecting beneath the peritoneal coat. 
On section these nodules are pale in appearance and soft 
in consistency. They are rarely found in the cervix. 
The submucous form of nodule may become polypoid, 
project into the cavity of the uterus, and with compara- 
tive frequency produce inversion of the uterus. 

The nodules of sarcoma differ from those of benign 
fibroid tumors in the fact that they have no capsule. 
They cannot be enucleated, but are intimately connected 
with the surrounding uterine tissue. Metastatic nodules 
occur in the vagina, the peritoneum, and in other parts 
of the body. 

In the later stages of the disease the nodules disin- 
tegrate and break down. 

It is probable that fibro-sarcoma usually, if not always, 
originates in a benign fibroid tumor. In the early stage 
of the disease the microscopic appearances of fibroid 
tumor are present, and the transition from the benign to 
the malignant growth may be studied. 

Symptoms. — The symptoms of this form of sarcoma 
resemble at first those of fibroid tumor; they are — hemor- 
rhage in the form of menorrhagia; a serous, non-odorous 
discharge; and a moderate degree of pain. 

Later, when ulceration and disintegration take place, 
the hemorrhage becomes more profuse and continuous. 
The discharge becomes fetid, and contains broken-down 
sarcomatous tissue. The pain becomes more severe. 
The uterus is enlarged, and the nodular outline may be 
determined by palpation. 

Before metastasis has taken place the differential diag- 
nosis between sarcoma and benign fibroid tumor can be 



228 A TEXT-BOOK OF DISEASES OF WOMEN. 

made only by microscopic examination of the discharge 
or of curetted or excised portions of tissue. The dura- 
tion of sarcoma of the uterus is about three years. 

Sarcoma may occur at almost any age. Hysterectomy 
has been performed for this disease in a girl of thirteen. 
Several cases have" been reported under twenty years of 
age. The most usual period is about the time of the 
menopause, in the decade from forty to fifty. 

The treatment of sarcoma of the uterus is immediate 
complete hysterectomy. If in the early stage a positive 
diagnosis cannot be made between benign fibroid and 
sarcoma, the woman should not be exposed to the dan- 
gers of waiting, but the uterus should be immediately 
removed. 

Chorio -epithelioma or syncytioma malignum is a 
rare and peculiar malignant growth of the uterus which 
occurs after pregnancy. It originates at the placental 
site from the epithelial cells covering the chorionic villi. 
It occurs during the course or after the termination of a 
uterine or tubal pregnancy. In typical cases the disease 
immediately follows labor at term, abortion, or a destroyed 
extra-uterine pregnancy. It may, however, remain latent 
for weeks or months. 

The tumor may be a nodular or pedunculated out- 
growth attached to the uterine wall ; a fungoid growth 
from the endometrium ; or an intramural growth covered 
with endometrium. The tumor varies in size from that 
of a cherry-stone to a mass several inches in diameter. 
It is composed of soft fragile spongy tissue, light or dark 
red in color, infiltrated with blood, and containing cir- 
cumscribed hemorrhages. Histologically the tumor con- 
sists of many types of cells irregularly placed ; syncytial 
tissue, cells derived from Langhans' layer, and some- 
times chorionic connective tissue. There are numerous 
cavities containing blood and connective tissue. 

Metastatic growths have a similar structure. Metas- 
tasis takes place through the vascular system and may 
reach distant organs — the lungs, liver, and spleen. 



CANCER AND SARCOMA OF THE UTERUS. 229 

Symptoms. — There is no characteristic symptom of 
chorio-epithelioma. The chief symptom is irregular or 
continuous hemorrhage from the uterus following a labor, 
an abortion, or an extra-uterine pregnancy. The body 
of the uterus is enlarged, and the cervical canal dilated 
as in cancer and sarcoma. A positive diagnosis can be 
made only by microscopic examination of tissue removed 
by the curet. 

Treatment. — As the disease is exceedingly malignant 
and of rapid growth, immediate hysterectomy is indi- 
cated. 



CHAPTER XX. 
FIBROID TUMORS OF THE UTERUS. 

Fibroid tumors originate in the muscular wall of the 
uterus. They are composed of elements resembling, to 
a greater or less extent, those that compose the middle 
uterine wall. They consist of connective tissue and of 
unstriped muscular tissue in varying proportions. Uterine 
tumors composed exclusively of muscular fibres — true 
myomata — very rarely occur. 

A number of names, based upon the proportion of the 
component elements, have been used by writers to desig- 
nate these tumors. They have been called fibroma, my- 
oma, myo-fibroma, and fibro-myoma. The natural his- 
tory of all the varieties is about the same, and varies but 
little with the proportion of the elements. I shall there- 
fore consider them under the general name of fibroid 
tumors of the uterus. 

Fibroid tumors of the uterus are benign, in the sense 
that they do not, like cancer, infiltrate contiguous struc- 
tures or infect the general system. 

Fibroid tumors are loosely attached to the surrounding 
uterine wall. They are usually invested by loose cellular 
tissue, forming a capsule from which they may easily be 
enucleated. Blood-vessels, usually of small size, connect 
the tumor with its capsule. Dense adhesion between the 
tumor and its capsule is the result of inflammatory 
action. The loose connection of the fibroid tumor with 
the surrounding structures explains the ease with which 
these tumors travel and are squeezed out of the uterine 

230 



FIBROID TUMORS OF THE UTERUS. 231 




Fig. 131. — Interstitial fibroid tumor of the uterus. A small submucous fibroid 
appears in the uterine cavity. 




Fig. 132. — Subperitoneal fibroid tumors of the uterus. 



232 A TEXT-BOOK OF DISEASES OF WOMEN. 

wall. It will be remembered that in this respect the 
fibroid differs from the nodule of cancer and of sarcoma. 

To the naked eye fibroid tumors present a white or 
rosy appearance. The intensity of the red color is, as 
a rule, proportional to the amount of muscular tissue. 
On section the bundles of fibrous tissue, arranged more 
or less concentrically about many axes, may be apparent. 
The vessels in the tumor itself are usually small and few 
in number. The large arteries and venous sinuses are 
found in the capsule. 

Fibroid tumors vary in hardness from the soft myoma 
to dense stony nodules composed almost entirely of fibroid 
tissue. 

Fibroid tumors vary in size from the smallest nodule 
in the uterine wall to a solid mass weighing one hundred 
and forty pounds. The tumors that usually come under 
observation weigh from one to ten pounds. 

Fibroid tumors occur most frequently in the body of 
the uterus. As has already been mentioned, however, 
they are sometimes found in the infra-vaginal portion of 
the cervix, and a peculiarly dangerous form of fibroid 
grows from the supra- vaginal cervix. 

Fibroid tumors are multiple in the great majority of 
cases. It is unusual to find a single fibroid nodule or 
tumor in the uterus. Sometimes one tumor far outgrows 
the rest, but if the uterine wall is carefully examined 
other small nodules will usually be found in its sub- 
stance. 

Fibroid tumors originate in the muscular wall of the 
uterus, and extend thence in various directions. When 
they are situated in the muscular wall they are said to be 
interstitial (Fig. 131). When they grow outward, so that 
they project beneath the peritoneum, they are called sub- 
peritoneal (Fig. 132). When they project into the ute- 
rine cavity they are called submucous (see Fig. 131). 

When the} 7 grow from the side of the uterus, and espe- 
cially from the supra-vaginal portion of the cervix, and 
extend outward into the cellular tissue between the folds 



FIBROID TUMORS OF THE UTERUS. 233 

of the broad ligaments, they are said to be intraliga- 
mentous (Fig. 133). 

The subperitoneal Jibroia 'may continue to grow, push- 
ing the peritoneum ahead of it, until the tumor becomes 
altogether extruded from the body of the uterus. It is 
then attached to the uterus only by a pedicle of varying 
thickness. The pedicle may be fibro-muscular in cha- 




Fig. 133. — Subperitoneal fibroids and an intra-ligamentous fibroid of the uterus. 

racter, or it may consist only of peritoneum, a little mus- 
cular tissue, and blood-vessels. 

Such a hard, freely movable tumor often causes a great 
deal of peritoneal irritation. A serous fluid may be 
thrown out by the peritoneum, and a moderate degree of 
ascites may occur. Adhesions may be formed between 
the fibroid tumor and contiguous structures — the abdom- 
inal parietes, the omentum, or intestines. These adhe- 
sions are often exceedingly extensive, firm, and vascular, 
so that in some cases the tumor derives its chief blood- 
supply and mechanical support from such adventitious 
attachments. The uterine pedicle may, as a result of 
progressive atrophy, traction, or violence from a fall, be- 
come detached, and the tumor, having then lost all ute- 
rine connection, appears to be a fibroid growth of the 



234 A TEXT-BOOK OF DISEASES OF WOMEN. 

omentum, intestine, or abdominal wall. This is the 
origin of many so-called fibroid tumors of these struc- 
tures. 

Detachment from the uterus may also occur, as the 
result of atrophy of the pedicle or of violence, in the 
case of a pediculated subperitoneal fibroid that has not 
contracted adhesions to other structures, and the tumor 
will then be found free in the abdominal cavity. 

The subperitoneal fibroid in its upward growth some- 
times drags the body of the uterus with it, and in this 
way may produce great elongation and distortion of the 
cervix. 

The submucous fibroid grows toward the uterine cavity. 
It presses the mucous membrane before it, and it may 
enter the cavity of the uterus, being altogether extruded 
from the uterine wall. It then forms a pediculated tumor 
lying in the uterus — an intra-uterine polyp. The pedicle 
is composed of dense fibro-muscular tissue, and is in- 
vested by a sheath of mucous membrane, unless this 
structure has been destroyed. The pedicle may be but 
slightly vascular, or it may rarely contain large arteries. 
As a general rule, the greater the degree of the extrusion 
of the polyp and the longer the pedicle, the less is the vas- 
cular supply. Rapid spontaneous hemostasis occurs after 
a fibroid polyp is cut from its pedicle, as a result of the 
thickness of the arterial walls and the contractility of 
the pedicle. 

The intra-uterine polyp, from prolonged pressure, some- 
times acquires the shape of the uterine cavity. 

Uterine contractions are excited by the presence of the 
polyp, and the tumor may in time be expelled from the 
uterus, enter the vagina, and protrude at the vulva. 

Submucous fibroids form the most usual variety of 
uterine polypi. In some cases the overlying mucous 
membrane becomes much stretched and attenuated, and 
may finally rupture or slough. The fibroid tumor may 
then escape through the opening in the mucous mem- 
brane, and, having been extruded altogether from the 



FIBROID TUMORS OF THE UTERUS. 235 

uterine wall, may be expelled from the body by uterine 
contractions. 

The fibroid polyp, being exposed to septic influences 
from the vagina, may become inflamed and suppurate; or 
sloughing and disintegration may occur because of inter- 
ference with the blood-supply in the pedicle. 

The intra-ligamentous fibroid grows from the side of the 
uterus or from the supra-vaginal cervix. It pushes apart 
the peritoneal folds of the broad ligament, and grows be- 
tween them or beneath them. The tumor is thus out- 
side of the peritoneum. It may fill the whole pelvis 
with a dense unyielding mass, pushing the uterus to the 
pelvic wall, destroying anatomical relations, and exerting 
most disastrous pressure upon blood-vessels, nerves, 
ureters, and other pelvic structures. 

Sometimes, as these tumors enlarge in an upward di- 
rection, they carry with them overlying pelvic organs; 
thus the ureter may be found passing over the top of a 
tumor which, beginning as an intra-ligamentous pelvic 
growth, has become abdominal. 

In some cases the fibroid grows from the posterior as- 
pect of the supra-vaginal cervix, passes beneath the 
bottom of Douglas's pouch, pushes the peritoneum above 
it, and becomes a retro-peritoneal tumor. 

Again, it may grow from the anterior aspect of the cer- 
vix in the vesico-uterine space, and as it extends upward 
may push the vesico-uterine fold of peritoneum above it 
and drag up the bladder, so that this viscus is sometimes 
found spread out upon the anterior face of the tumor and 
extending as high as the umbilicus. 

As has already been said, fibroid tumors are usually 
multiple, and if one of the terms designating the position 
of the tumor as subperitoneal or intra-ligamentous is 
used to describe any case, we understand that the chief 
tumor-mass is of this character. 

The fibroid polyp is more likely to be single than any 
of the other varieties. In fact, the fibroid polyp is usu- 
ally single; that is, no other fibroid tumor can be detected 



236 A TEXT-BOOK OF DISEASES OF WOMEN. 

in the body of the uterus. This is not always the case, 
however, and sometimes the repeated expulsion of suc- 
cessive fibroid polypi from the same woman renders it 
probable that several nodules were simultaneously pres- 
ent in the uterine wall. 

As a rule, fibroid tumors of the uterus are of slow 
growth. In some cases five, ten, or fifteen years may 
elapse before the tumor attains the size of the fetal or the 
adult head. Sometimes the tumor appears to be of lim- 
ited growth, and early attains its maximum size, or it 
may not increase at all in size after its first discovery by 
the woman; in other cases the tumor slowly but steadily 
grows until, after a lapse of ten or twenty years, it fills 
the whole of the abdominal cavity and renders the woman 
helpless from weight and pressure; and, finally, in some 
instances the tumor grows unlimitedly with the rapidity 
characteristic of an ovarian cyst, and in one or two years 
may crowd the woman out of existence. This rapid un- 
limited growth is characteristic of tumors of the fibro- 
cystic variety. 

A fibroid tumor causes very marked changes in the 
body of the uterus — the muscular coat and the endome- 
trium. The whole uterus becomes enlarged. The cavity 
is increased in length, and the muscular wall becomes 
often very much hypertrophied. This hypertrophy re- 
sembles that occurring in pregnancy. Even small fibroid 
tumors may produce this condition, which seems to de- 
pend more upon the position than upon the size of the 
growth. The interstitial and the submucous tumors are 
accompanied by a greater degree of uterine hypertrophy 
than accompanies the subperitoneal growths. In some 
cases the uterus may be of normal size if the subperito- 
neal growth has become pedunculated. The uterus may 
appear to be uniformly enlarged to the size of the fourth 
or fifth month of pregnancy, and when incised it will be 
found to contain one or more interstitial or subperitoneal 
tumors that have become encapsulated by it. When such 
a case is subjected to celiotomy the resemblance of the 



FIBROID TUMORS OF THE UTERUS. 237 

uterus to pregnancy is very striking. Between such a 
smooth, uniformly enlarged uterus on the one hand, and 
the irregular, distorted mass of subperitoneal fibroids on 
the other, there are an infinite number of varieties. A 
great increase in the vascular supply accompanies the hy- 
pertrophy of the uterus. The ovarian and uterine arteries 
and their branches become very much hypertrophied, 
while the veins in the broad ligaments and the sinuses 
in the capsule of the tumor become enormous. 

The endometrium shares in the changes that take place 
in the uterus. It is, of course, increased in area with 
the increase of the uterine cavity. There may be atro- 
phic changes from pressure upon or tension of this mem- 
brane, or various forms of endometritis may be present, 
most usually the interstitial and the glandular. The 
glandular form of the disease is said to occur most fre- 
quently when the tumor is remote from the cavity of the 
uterus, as in the subperitoneal variety; while interstitial 
endometritis occurs with the submucous and the inter- 
stitial tumors. 

In the Fallopian tubes and the ovaries pathological 
changes occur as the result of uterine fibroids. The 
tubes may present any of the forms of cystic change — 
hydrosalpinx, pyosalpinx, or hematosalpinx — that are 
caused by salpingitis. It is probable that these diseases 
are often caused by extension of endometritis. The tubes 
and ovaries may be much distorted and displaced from 
the normal position. In some cases the ovary is drawn 
out into a long cord five inches in length ; in other cases 
it is spread out upon the face of the tumor. 

Fibroid tumors are liable to several forms of degenera- 
tion — calcareous, fatty, myxomatous, edematous, cystic, 
telangiectatic, gangrenous or suppurative, necrobiotic, 
and malignant. 

Calcareous change, from the deposit of lime-salts in 
the fibroid nodules, is an unusual occurrence. It appears 
most often in women beyond the menopause, and is part 
of the atrophic changes that take place at this time. (It 



238 A TEXT-BOOK OF DISEASES OF WOMEN. 

has occurred in a woman who had been subjected to 
oophorectomy for the relief of a fibroid tumor.) 

I have seen a fibroid tumor the size of the adult head 
— a solid calcareous mass which could be divided only 
by means of a saw. 

The calcareous nodules are surrounded by uterine tissue 
to which they are but loosely attached. They may be 
forced out of the uterus and escape at the vulva. They 
have been called "womb-stones." 

Fatty degeneration is a very unusual condition. It has 
been assumed to take place, as a step preliminary to ab- 
sorption, in those cases in which a fibroid tumor dis- 
appears after labor or from other cause. 

Myxomatous degeneration is also rare. In it an effusion 
of mucous fluid takes place between the bundles of fibrous 
tissue. Sometimes large cavities are formed in this way. 

In the edematous fibroid the whole tumor is permeated 
by a serous fluid. This condition is not unusual. It 
resembles edema in any other part of the body. It is. 
often found in young women before the thirtieth year. 

Cystic degeneratio7i of fibroid tumors may result from 
any of the forms of degeneration with softening in which 
cystic cavities are formed. 

In some cases fibro-cystic tumors are caused by dilata- 
tion of the lymphatics. They have been called ' ' lym- 
phangiectatic fibroids." An endothelial lining has occa- 
sionally been found in the cystic cavities of these tumors. 
The fluid removed from the cyst-cavities coagulates spon- 
taneously. Such fibroids have frequently been mistaken 
for ovarian cysts. 

In the telangiectatic or the cavernous form of fibroid 
tumor there is an enormous dilatation of the vessels in 
the new growth. The venous spaces are sometimes as 
large as a walnut, and are filled with clotted or fluid 
blood. This change usually affects one part, and not all, 
of the tumor, which presents the gross appearance of a 
sponge soaked with blood. 



FIBROID TUMORS OF THE UTERUS. 239 

Gangrene is most liable to occur in the fibroid polyp. 
During the process of expulsion from the uterus the vas- 
cular supply through the pedicle becomes impeded, so 
that there is not sufficient blood for nutrition. The 
tumor is exposed to septic infection through the vagina 
and the cervix, and sloughing and suppuration occur. As 
a result of such disintegration the tumor may be dis- 
charged piecemeal. 

Inflammation, and occasionally supptiration, of fibroid 
tumors remote from the cavity of the uterus may occur 
from infection through the intestinal tract or other 
channel. 

Necrobiosis occurs if the nutrition of the fibroid is cut 
off and there is no infection of the dead tissue. The 
tumor becomes soft, undergoes fatty degeneration, and 
liquefies. The necrobiotic degeneration may involve 
only part or all of the tumor. There is always danger 
of septic infection occurring in this form of degeneration. 

Sarcoma may develop in a fibroid tumor of the uterus. 
As has already been stated, the "circumscribed fibroid 
sarcoma," or sarcoma of the uterine parenchyma, is 
thought by some authorities always to originate from 
degeneration of a benign fibroid tumor. It seems prob- 
able that the fibroid tumor predisposes the woman to the 
development of sarcoma of the uterus. 

Cancer may also occur in the endometrium of a fibroid 
uterus. This occurrence is by no means an unusual one. 
We cannot yet say positively that the fibroid favors the 
development of cancer, but it seems probable that the 
diseased endometrium that accompanies fibroids furnishes 
a place of diminished resistance for the development of 
malignant disease. 

Martin has made an interesting analysis of 205 cases 
of fibroid tumor of the uterus that had been submitted to 
operation. From this analysis we may form some esti- 
mation of the frequency of the various forms of de- 
generation that have been described. 



240 A TEXT-BOOK OF DISEASES OF WOMEN. 

Fatty degeneration existed in 7 cases. Calcification was 
present in 3 cases. In 10 cases there was suppuration, 
and this process was found in the submucous, interstitial, 
and subperitoneal tumors. In n cases there was exten- 
sive edema of the fibroid. In 8 cases the tumors had 
become cystic. 

The telangiectatic change was found to a marked de- 
gree in 3 cases. 

Sarcomatous degeneration had occurred in 6 cases. 

In 7 cases the fibroid was complicated with cancer of 
the fundus uteri, and in 2 cases with cancer of the neck 
of the womb. 

The fatty and calcareous changes are not to be con- 
sidered dangerous forms of degeneration. 

The other changes, however, are often attended with 
great danger to life. The dangers of suppuration and of 
sarcomatous degeneration are obvious. The edematous 
fibroid is often of rapid and unlimited growth, and is usu- 
ally accompanied by profuse hemorrhages from the uterus. 
The cystic fibroid may grow as rapidly and as large as an 
ovarian cyst. The telangiectatic tumors grow to large 
size and are attended by the dangers of thrombosis and 
embolism. 

Cancer of the fundus with fibroid tumor may only be 
a coincidence, and we will not assume that predisposition 
to cancer is caused by the fibroid. 

The statistics that have been given, however, show 
that in at least 38 cases out of 205, or in about 18 per 
cent, of the cases, changes took place in the fibroid that 
seriously endangered the life of the woman. 

Sterility, abortion, and difficult or impossible labor are 
caused by uterine fibroids. Conception is impeded on 
account of the displaced, distorted uterus and the hem- 
orrhage and discharge. Abortion is likely to occur, on 
account of the endometritis and the unequal expansibility 
and the irritability of the uterus. 

Ivabor is sometimes rendered impossible by the pres- 



FIBROID TUMORS OF THE UTERUS. 241 

ence of a uterine fibroid that obstructs the pelvis, and 
Cesarean section has been performed for this cause. 

The cause of fibroid tumor of the uterus is unknown. 
Some authorities consider the condition, or at least the 
predisposition to the condition, to be congenital. Ute- 
rine fibroids have been observed in girls near the age of 
puberty, and hysterectomy for fibroid has been performed 
at the age of eighteen. 

Usually the disease begins to cause symptoms, and first 
comes under the observation of the physician, after the 
thirtieth year. It is very probable that small interstitial 
or subperitoneal fibroids exist in many women before this 
period, but, on account of the small size and the position 
of the growths, they produce no marked symptoms, and 
if the woman bears children, the tumors are very likely 
absorbed during the process of uterine involution. 

Fibroid tumors occur in both the white and the black 
races — with somewhat greater frequency in the latter 
than in the former. Tait says that fibroid tumors of the 
uterus are unknown among the black women of Africa. 
The disease is certainly very common among their de- 
scendants in this country. 

The frequency of uterine fibroids is difficult to deter- 
mine, for there are many cases in which the disease is 
unrecognized on account of the small size of the tumor 
and the absence of symptoms. It is, however, one of 
the commonest diseases with which women suffer. In 
a series of 504 celiotomies performed for diseases of 
women at the University and Gynecean Hospitals, uter- 
ine fibroids were found in 85, or in about 17 per cent, of 
the cases. 

Fibroid tumors are found both in multiparous and in 
nulliparous women — much more frequently in the latter 
than in the former. Single women and sterile married 
women are especially predisposed to this disease. There 
are two probable causes for this difference. The unceas- 
ing congestions of menstruation favor the development 

16 



242 A TEXT-BOOK OF DISEASES OF WOMEN. 

of the neoplasm ; and, when once started, its further 
growth is not checked by the retrograde changes that 
accompany involution of the uterus, and that sometimes 
cause the disappearance of even large fibroids. 

Fibroid tumors are essentially growths of the men- 
strual life of the woman. They usually first appear after 
the thirtieth year, and they continue to grow until the 
menopause. The size of the tumor and the severity of 
all the symptoms progressively increase during the active 
sexual period of life. It is very unusual for favorable 
retrograde changes or permanent amelioration of symp- 
toms to occur during this period. In a woman with 
fibroid tumor of the uterus the menopause is delayed for 
five to fifteen years beyond the normal time. This is an 
important fact to be remembered in connection with the 
prognosis and the treatment of any case. 

At the menopause, in the majority of cases, the growth 
of the tumor is arrested, and the retrograde changes that 
affect the genital apparatus involve also the fibroid tumor, 
and atrophy of the neoplasm, with marked diminution in 
size, and in some cases, its complete disappearance, may 
take place. The tumor becomes quiescent, and the 
woman may finish her life in comparative comfort. This, 
however, is by no means always the case. The fibroid 
sometimes continues to grow after the menopause, and 
the suffering is sometimes so unbearable that the woman 
is finally driven to operation. 

In some cases the tumor has developed entirely after 
the menopause has been reached. 

At each menstrual period there is usually a decided in- 
crease in the size of the tumor and in the severity of the 
symptoms. And at these periods, in the case of a sub- 
mucous or an interstitial fibroid, the cervical canal be- 
comes more patulous. 

Symptoms. — The chief symptom of fibroid tumor of 
the uterus is hemorrhage. This symptom is present in 
the great majority of fibroids of all kinds. It is not, 



FIBROID TUMORS OF THE UTERUS. 243 

however, universally present. I have removed tumors 
the size of the adult head, composed of interstitial and 
subperitoneal fibroids, from women who had never suf- 
fered with even slight menorrhagia. The hemorrhage 
appears in the form of menorrhagia or metrorrhagia. It 
may be an increase in the regular menstrual bleeding. 
It may appear as a periodical bleeding occurring every 
two weeks — a phenomenon that occurs in other diseases 
of the uterus and the endometrium. It may appear as a 
show of blood or a slight hemorrhage, after unwonted 
effort, between the regular menstrual periods. This may 
occur after straining at stool, coitus, or even emotional 
disturbance. And, finally, it may appear as a continuous 
bleeding from the uterus. 

The cause of these hemorrhages is to be found in the 
increased area of the endometrium accompanying the 
uterine enlargement, and in the diseased condition of the 
endometrium. 

The hemorrhage is not usually alarming in amount, 
and it may be somewhat controlled by rest in bed and the 
administration of ergot or other drugs. In some cases, 
however, it produces the most profound anemia, and in 
others, especially in the uterine polyp, the woman may 
literally bleed to death. 

The symptom of hemorrhage is independent of the size 
of the tumor, but depends upon the position of the 
fibroid. As a rule, the hemorrhage is most severe with 
the uterine polyp, less severe with the submucous and 
the interstitial tumors, and least with the subperitoneal 
variety. In some cases, when the mucous membrane 
overlying a submucous tumor ruptures, the hemorrhage 
may come directly from venous sinuses in the capsule. 

The hemorrhage also depends upon the variety of the 
growth. The edematous fibroid and the soft myoma ap- 
pear always to be accompanied by profuse bleeding. In 
some cases the hemorrhage may occur periodically or 
continuously in old women who have passed the meno- 



244 A TEXT-BOOK OF DISEASES OF WOMEN. 

pause, and in whom there had been no bleeding for 
several years. This has been observed in the small sub- 
mucous fibroids which, after a period of quiescence, have 
gradually become polypoid, or which have undergone 
suppuration and disintegration. The hemorrhage, the 
offensive odor of the discharge, and the age and the 
history of the patient are very likely to lead to the diag- 
nosis of cancer. 

The blood that escapes from the fibroid uterus may be 
fluid or clotted, or it may be partly decomposed from the 
retention of clots. 

A profuse secretion from the utricular glands often 
occurs between the uterine hemorrhages. This secretion 
is usually thin and watery in character, and may be so 
profuse as to require the continuous wearing of a napkin. 
In some unusual cases there is no marked hemorrhage, 
but a continuous abundant watery discharge. 

Pain is a more or less constant accompaniment of 
fibroid tumors. It varies a great deal in character and 
position. It is often referred to the sacrum and to the 
top of the head or the occiput. Pain of this character 
is due to the accompanying metritis and endometritis. 
That it is uterine in origin is shown by the fact of its 
complete and permanent disappearance from the day that 
hysterectomy is performed. 

The pain is always increased at the menstrual periods, 
and may at first be present only at these times. It after- 
wards becomes continuous. 

In the case of a submucous or a polypoid fibroid there 
may be present the pain of uterine contractions, referred 
to the center of the lower abdomen, and resembling 
labor-pains. 

The pain from pressure is sometimes intense. It occurs 
in large tumors and in those of pelvic growth, like the 
intra-ligamentous fibroids. Sciatic or crural neuralgia 
may be thus developed. 

In all these cases there is a feeling of weight and drag- 



FIBROID TUMORS OF THE UTERUS. 245 

ging in the pelvis which is most marked in the erect po- 
sition, and which is caused by the weight of the tumor 
and of the enlarged uterus. 

The symptoms of pressure are very marked in the case 
of intra-ligamentous tumors. The capacity of the bladder 
may be so diminished that there may be continuous in- 
continence of urine; or the bladder and the urethra may 
be so distorted, from traction and pressure, that urine is 
voided with great difficulty, and it is sometimes impos- 
sible to introduce the catheter. I have seen a woman 
with a fibroid the size of the adult head who could uri- 
nate only when upon her hands and knees. 

Pressure upon the pelvic nerves may, as has already 
been mentioned, produce great pain, and in some cases 
paralysis. Women are sometimes affected with sudden 
complete paralysis of one or both legs from the pressure 
of a fibroid. I have performed hysterectomy upon a 
woman who had on several occasions fallen helpless in 
the street from paralysis of the left leg caused by the pres- 
sure of a small intra-ligamentous fibroid tumor. All the 
pressure-symptoms are exaggerated at the menstrual 
period, on account of the swelling of the tumor that 
occurs at this time. 

Pressure upon the rectum is often very marked, and 
may cause constipation and hemorrhoids. Pressure upon 
the ureters causes dilatation, hydronephrosis, and ure- 
mia. This is a not infrequent cause of death, both in 
the untreated case and after operation for the relief of 
fibroids. 

The effect of fibroid tumors of large size upon the heart 
and blood-vessels has been remarked by several writers. 
Fatty degeneration and brown atrophy have been found 
associated with uterine fibroids in a number of instances. 
This is undoubtedly the explanation of some cases of 
death after operation. 

Martin has called attention to the disposition to throm- 
bosis and embolism which seems to be especially marked 



246 A TEXT-BOOK OF DISEASES OF WOMEN. 

in the telangiectatic form of tumor. This also explains 
some of the cases of sudden death that occur after opera- 
tion. Operators have observed cases of sudden death, 
probably from embolism, occurring sometimes several 
weeks after hysterectomy for fibroid tumor. 

The diagnosis of uterine fibroids is made from a study 
of the symptoms already described and from the physical 
examination. 

If the tumor is large enough to be palpated through 
the abdominal wall, the hard consistency and the irregu- 
lar bossed outline of the multinodular form of fibroid may 
be detected. 

By bimanual examination we determine the general 
enlargement, and perhaps the irregular outline, of the 
uterus. Sometimes, when the fibroid is small and inter- 
stitial, a slight elevation, or perhaps merely a local in- 
duration, may be felt. By grasping the cervix with a 
tenaculum and drawing it down while the palpating finger 
is in the rectum the whole of the posterior face of the 
uterus may be explored and small fibroid nodules dis- 
covered. 

The tumors are found to be continuous with the uterus 
and movable with it. If the tumor is sufficiently large to 
be grasped by an assistant, who draws it up or to either side, 
it will be found that the motion is communicated to the 
vaginal cervix. The cervix is often very hard, and may 
have been dragged upward to such an extent that it can- 
not be reached by the vaginal finger; or it may project 
from the rounded surface of the tumor like the nipple on 
the breast. 

The hard, non-fluctuating character of the tumor may 
usually be determined by bimanual examination. A sen- 
sation resembling that of fluctuation may be elicited in 
the edematous fibroid, and true fluctuation is, of course, 
present in the cystic variety. 

The uterine sound shows the increased length and the 
irregularity of the uterine cavity. The sound is not often 



FIBROID TUMORS OF THE UTERUS. 247 

necessary for diagnosis. It is useful, however, in the case 
of small interstitial fibroids. It will be remembered that 
uterine enlargement is one of the most usual symptoms 
of fibroid tumor. 

The presence in the wall of the uterus of a hard nodule 
or of an area of induration, with a decided increase in the 
length of the uterine cavity (three to four inches), is strong 
evidence of fibroid tumor. 

Those fibroid tumors which cause symmetrical uterine 
hypertrophy without any irregularity of surface are some- 
times difficult of diagnosis. They have been mistaken 
for the pregnant uterus. The reverse mistake has also 
very frequently been made, and the woman has been sub- 
jected to celiotomy for fibroid tumor when a normal preg- 
nancy alone was present. The differential diagnosis be- 
tween fibroid and pregnancy is usually not difficult. In 
making such a differential diagnosis it must be remem- 
bered that in some cases of pregnancy the menstrual pe- 
riods continue during the early months or throughout the 
course of pregnancy, and that irregular bleeding may 
occur during pregnancy; also, on the other hand, that 
the symptoms of menorrhagia and metrorrhagia may be 
absent in the case of fibroid tumors. Mammary changes, 
nausea, and pigmentation of the skin may occur with 
fibroid tumors as with other diseases of the uterus or 
the ovaries, and resemble the similar phenomena of preg- 
nancy. The bluish discoloration of the ostium vaginae, 
the soft cervix, the pulsation of the vaginal vessels, the 
movements of the child, and the fetal heart-sounds are 
absent in fibroid tumors. The recent history of the 
tumor and its typical increase in size are observed in 
pregnancy. 

In the event of doubt the case should be watched for 
a few months until the diagnosis becomes clear. Fibroid 
tumors are of slow growth, and such delay is usually not 
dangerous. 

If the fibroid tumor is complicated with pregnancy, 



248 A TEXT-BOOK OF DISEASES OF WOMEN. 

the diagnosis becomes more difficult. This complica- 
tion is not an unusual one, and should always be borne 
in mind. 

The differential diagnosis between uterine fibroid and 
ovarian cyst is easy except in the case of the fibro-cystic 
tumor. Such tumors have very often been mistaken for 
ovarian cysts. The mistake is not at all serious, as celi- 
otomy is indicated in either case. The operator, how- 
ever, should always determine the nature of the tumor 
before proceeding with the operation after the abdomen 
has been opened, as puncture of a fibro-cystic tumor may 
be attended by alarming hemorrhage. 

A small fibroid in the posterior wall of the uterus has 
often been mistaken for retroflexion, and the woman has 
been treated with a pessary. This mistake may be 
avoided by feeling, with the abdominal hand, the fundus 
uteri in its normal forward position, or by determining 
the true direction of the uterus with the uterine sound. 

The prognosis of uterine fibroids may be determined 
from a consideration of the natural history, the degenera- 
tions, and the complications of these neoplasms, which 
have already been described. 

Fibroid tumors are benign growths, in contradistinction 
to cancer and sarcoma. They do not infiltrate contigu- 
ous structures or invade the general system ; but they are 
not benign in the sense that they are not dangerous to 
life. 

As has been said, the disease may terminate as a ute- 
rine polyp, which may be discharged from the body. But 
during this process the woman may die from hemor- 
rhage or from septic absorption from the sloughing, dis- 
integrating tumor. 

Some unusual fibroids give no trouble whatever, never 
attain a large size, and are discovered only accidentally 
during the life of the woman or at the autopsy. 

In very exceptional cases — so rare that they are to be 
looked upon as medical curiosities^the fibroid disappears 



FIBROID TUMORS OF THE UTERUS. 249 

spontaneously even after it has reached a large size. 
This has occurred as the result of an accident, explora- 
tory celiotomy, and pregnancy. 

We have no right in any case, however, to look for 
such favorable termination. 

The accidents that may happen to the tumor itself, and 
which imperil the life of the woman, are various and 
occur frequently. The dangerous forms of degeneration 
— the edematous, the cystic, the telangiectatic, and the 
sarcomatous — occur with sufficient frequency always to 
be dreaded; and, even though these dangers be avoided, 
the anemia from the continual hemorrhage exposes the 
woman to fatal results from the diseases and accidents of 
daily life. The most favorable course that we have a 
right to expect, in any case of fibroid tumor of the uterus 
that is not discharged as a uterine polyp, is that it will 
grow slowly, that it will produce symptoms not unen- 
durable, and that at the menopause it will cease to grow 
and will atrophy or disappear. 

This comparatively favorable course condemns the 
woman to a life of invalidism, more or less marked, dur- 
ing the years that should be the most useful and active 
of her existence The menopause may be delayed for 
five, ten, or fifteen years, or it may be indefinitely post- 
poned ; and even after the menopause has occurred, in a 
certain number of cases the fibroid, contrary to the usual 
rule, continues to grow, and may ultimately cause death. 

Treatment of Fibroid Tumors of the Uterus. — 
Operative treatment is usually demanded in the case of 
fibroid tumors. A few years ago the treatment usually 
advised was palliative and expectant. The imperfect 
technique rendered operations for this disease so fatal 
that it was considered safest for the woman to allow the 
tumor to pursue its natural course, hoping that, if small 
and single, it would be discharged as a polyp, or that it 
would grow slowly and would atrophy at the menopause, 
the physician meanwhile relieving as much as possible. 



250 A TEXT-BOOK OF DISEASES OF WOMEN. 

by palliative treatment, the symptoms that presented be- 
fore this favorable termination. 

Many women, following this advice, have suffered 
through the years of active life, and have finally found 
relief and cure when the menopause was reached; others 
have started upon this dreary course, and have died from 
some of the accidents incident to these tumors; still 
others have passed through these years of suffering, and 
then have found the hoped-for goal vanished, the meno- 
pause indefinitely postponed, or the tumor continuing to 
grow after this period had been reached. 

Many of these women are driven to the operating-table 
to-day, after lives that have been wasted by this expectant 
plan of treatment. 

The great majority of fibroid tumors of the uterus 
demand immediate operation. The operative technique 
has been so perfected that the mortality after operation is 
very small. The danger of operation is much less than 
the dangers to which the woman is exposed from the 
various accidents that are liable in this disease. 

There are some cases, however, in which immediate 
operation is not demanded. In a young woman with a 
fibroid tumor of small size that is not causing serious 
symptoms operation may be deferred and the case may 
be watched. This plan is especially desirable if the 
woman is anxious to have children. She should be told, 
however, that conception is less likely to occur than in 
the well woman, that she is liable to abort, and that the 
tumor will grow more rapidly during her pregnancy. 
On the other hand, there is the possibility of its disap- 
pearance after labor. 

If the tumor, even though small, is intra-ligamentous 
and of pelvic growth, the expectant plan of treatment is 
not justifiable. Dangerous pressure-symptoms are too 
imminent, and if pregnancy occurs labor will be ob- 
structed. If the woman has reached the menopause, if 
menstruation has ceased, and the tumor is causing no 



FIBROID TUMORS OF THE UTERUS. 251 

serious symptoms from its size and position, the case may 
be watched with the hope that the disease will shortly 
become quiescent. Such cases are exceptional. Usually 
the tumor produces symptoms that render the woman 
more or less of an invalid, and she should not be con- 
demned to this suffering and to the dangers of waiting. 
In these cases we must not rely altogether upon the state- 
ment of the woman in regard to the suffering caused by 
the tumor. A woman, dreading operation, will often 
underrate her suffering, or she will consider as normal 
the disturbances to which she has, through a long period 
of years, gradually become accustomed. 

No drug has been discovered that has any influence 
upon the growth of the fibroid tumor. 

The most serious symptom, hemorrhage, may be alle- 
viated in a variety of ways. Rest in the recumbent pos- 
ture, to relieve congestion, is most important. Such rest 
is especially demanded at the menstrual period. Pres- 
sure-symptoms and pain are likewise relieved by rest. 
Careful attention to the regularity of the bowels is desir- 
able. The administration of saline purgatives to the 
extent of mild purgation depletes the pelvic circulation, 
and is especially useful immediately before a menstrual 
period. Coitus should be avoided immediately before 
and during the menstrual period. 

Ergot, gallic acid, hydrastis, bromide of potash, and 
erigeron are useful to control the bleeding. They should 
be administered in frequently repeated doses for a long 
period. 

Thorough curetting of the cavity of the uterus is the 
most certain method of controlling the hemorrhage. By 
this procedure the diseased endometrium is removed, and 
the bleeding is usually very decidedly diminished for sev- 
eral mouths afterwards. 

The treatment by electricity, once popular with some 
physicians, has not stood the test of time and experience. 
It does not stop the growth of the tumor. It has caused 



252 A TEXT-BOOK OF DISEASES OF WOMEN. 

many deaths. It may produce peritoneal adhesions, 
which render subsequent operation most difficult. 

Ligature of the arteries supplying the uterus has been 
performed with the object of arresting the growth of a 
uterine fibroid. The results of this operation, however, 
have not been satisfactory. 

Salpingo-oophorectomy has been practised for a number 
of years, and a large number of fibroid tumors have been 
cured by it. Before the present perfected technique of 
hysterectomy had been developed salpingo-oophorectomy 
was much the safer operation, and was always practised 
whenever possible. 

The object of the operation is to cause arrest of growth 
and atrophy of the tumor by stopping menstruation and 
producing a premature menopause. 

According to the statistics of Tait, the operation results 
in cure of the fibroid in 95 per cent, of the cases. 

In some cases the bleeding stops immediately and never 
recurs; in other cases the bleeding continues, in steadily 
diminishing amount, for several weeks or a few months 
after the operation ; and finally, in a small proportion of 
the cases, the bleeding is not arrested at all. 

The atrophy of the tumor after this operation is also 
variable. Sometimes the atrophy begins immediately, 
and in a few weeks after the operation has proceeded to 
a very marked degree, the tumor disappearing or being so 
small as to give no trouble; in other cases the atrophy 
is much slower; sometimes there is no arrest of growth 
whatever. 

The operation seems to produce most benefit in cases 
of the hard fibroid. The edematous fibroid is often un- 
affected by it; and it is not applicable in the case of fibro- 
cystic tumors, which continue in unabated growth. 

In performing the operation it is important that every 
portion of ovarian tissue should be removed, and that the 
Fallopian tube should be amputated as closely as possible 
to the uterine cornu. Many cases of failure of this ope- 
ration are due to neglect of these precautions. 



FIBROID TUMORS OF THE UTERUS. 253 

A very small portion of ovarian tissue may be sufficient 
to continue menstruation. 

A good many women who had derived no benefit from 
the first operation have been subjected to a second opera- 
tion, a small remaining portion of the ovary being re- 
moved or the stump of the Fallopian tube being excised, 
complete cure resulting. 

The nature of the influence of the Fallopian tube in 
this matter is not understood. Tait lays especial stress 
upon the necessity of its complete removal. 

The importance of the removal of the tubes may be 
realized from Tait's statement that " removal of the ova- 
ries alone is followed by immediate and complete arrest 
of menstruation in about 50 per cent, of the cases. Re- 
moval of both tubes, with or without the ovaries, is fol- 
lowed by the same arrest in about 90 per cent, of the 
cases." From this statement it appears that if one wishes 
to stop menstruation, removal of the tubes is of even 
more importance than removal of the ovaries. 

The operation of salpingo-oophorectomy is not advis- 
able in some cases, and in some others it is impossible to 
perform it. 

As has already been said, the operation is likely to fail 
in the soft edematous fibroids. It should not be advised 
in the fibro-cystic tumors. It is not advisable in the case 
of large fibroid tumors of abdominal growth, because, 
even though atrophy occur, it will be slow, and the symp- 
toms referable to the large hard tumor in the abdomen 
will be but slowly relieved. 

The operation is not applicable to the intra-ligamentous 
fibroid of pelvic growth, producing urgent pressure- 
symptoms that demand certain and immediate relief. In 
the case of profuse exhausting hemorrhage, when the 
anemia is so great that immediate and certain arrest of 
bleeding is required, salpingo-oophorectomy should not 
be practised. 

If the woman has reached the menopause, and, not- 



254 A TEXT-BOOK OF DISEASES OF WOMEN. 

withstanding the cessation of menstruation, the tumor 
continues to grow, salpingo-oophorectomy will do no 
good. 

In some cases the tubes and ovaries cannot be removed. 
They often occupy a position behind or under the tumor, 
so that they cannot be removed without first taking the 
tumor away. The tube and ovary may be so distorted 
that only partial excision is possible, and this will result 
in no benefit; or the tube and ovary may be spread out 
upon the face of the tumor, incorporated with its capsule, 
so that removal is impossible, and any attempt at removal 
may result in rupture or penetration of large venous 
sinuses — a most dangerous accident. 

The operator should therefore never undertake the 
operation of salpingo-oophorectomy for uterine fibroid 
unless he is prepared to perform hysterectomy if this 
operation is found necessary. 

Hysterectomy is deservedly the favorite operation for 
uterine fibroids at the present day. 

The danger of the operation is small, being but little, 
if any, greater than that attending salpingo-oophorec- 
tomy for fibroids, if we compare only those cases in which 
either operation may be performed. 

The operation is applicable to every kind of fibroid 
tumor. The relief of symptoms is immediate and cer- 
tain. 

The reflex symptoms, such as backache and headache, 
which are directly due to the pathological condition of 
the uterus, often disappear immediately and permanently. 
This cannot be said of salpingo-oophorectomy, after 
which operation these symptoms often continue for an 
indefinite period. 

The treatment of uterine fibroids has followed in de- 
velopment the growth of abdominal and pelvic surgery. 
In the days when celiotomy was a dangerous operation 
the palliative treatment was advisable. When salpingo- 
oophorectomy could be safely performed this treatment 



FIBROID TUMORS OF THE UTERUS. 255 

was practised ; and now that hysterectomy is equally safe, 
it has become the operation of election. 

The details of the operation of hysterectomy for 
uterine fibroids will be considered in a subsequent 
chapter. 

Myomectomy (Abdominal). — In some cases of uterine 
fibroid it is possible to remove the tumor without taking 
away the uterus. This operation, when performed 
through an abdominal incision, is called abdominal 
myomectomy. From a surgical standpoint it is the ideal 
plan of treatment, as the woman is cured of the disease 
without suffering mutilation. 

Myomectomy is especially adapted to the treatment of 
single fibroid tumors which may be excised or shelled 
out of the body of the uterus. It is indicated in the 
case of young women who are anxious for children. 

The field of myomectomy is at present a limited one. 
Single subperitoneal and interstitial fibroid tumors are 
rare. Even though the secondary nodules may be small 
at the time of operation, they will grow after the removal 
of the chief mass. Hysterectomy has been required at a 
second operation in a woman on whom myomectomy had 
been first performed. 

The operation is still on trial: its limitations and 
remote results have not yet been determined. It should 
be performed only by the experienced abdominal surgeon. 
Many fatal cases of post-operative hemorrhage and of 
sepsis have occurred. Though successful cases have 
been reported by men of unusual skill and experience, in 
which large numbers of uterine fibroids have been re- 
moved from the uterus at one operation, yet these cases 
must be looked upon as rare surgical triumphs which it 
is to be hoped will become more frequent in the future. 

On the ground of safety, hysterectomy is to be preferred 
to myomectomy. 

The details of the operation of myomectomy are 
described in a subsequent chapter. 



256 A TEXT-BOOK OF DISEASES OF WOMEN. 

When the fibroid tumor is complicated by pregnancy 
it may be necessary to perform Cesarean section, followed 
by hysterectomy. This is not justifiable, however, un~ 
less the fibroid is so situated that the passage of the child 
by the natural way is impossible. The fibroid usually 
increases more rapidly in size during pregnancy, but may 
diminish a good deal with the involution of the uterus. 

Treatment of the Fibroid Polyp. — When the fibroid 
tumor is polypoid, and projects into the uterine cavity, or 
the cervix, or beyond the external os, none of the opera- 
tions that have just been described are required. The 
tumor should then be attacked by way of the vagina. 
If the fibroid polyp projects from the external os, the 
pedicle may very easily be divided with curved scissors. 




FlG. 134. — Fibroid polyp producing partial inversion of the uterus. 

If the tumor is still within the cavity of the uterus, it 
will be necessary to dilate the cervix, or to enlarge the 
canal by lateral incisions, so that the pedicle may be 






FIBROID TUMORS OF THE UTERUS. 257 

reached. It should always be remembered that the polyp 
may, by traction, produce partial or complete inversion 
of the uterus (Fig. 134), and in dividing the pedicle, 
therefore, the operator should cut close to the tumor, 
leaving, if necessary, a portion of the surface of the 
tumor. In case the polyp is so large that the vagina is 
filled to such an extent that the pedicle is not accessible, 
it is advisable to remove the tumor piecemeal, grasping 
portions with a tenaculum and cutting away with scissors 
until the pedicle is reached. The fibroid polyp is not 
vascular, and hemorrhage is not alarming. The pedicle 
usually contains no large vessel. It retracts after the 
tumor has been cut away, and spontaneous hemostasis is 
secured. It was formerly the custom to ligate the pedicle 
or to remove the polyp with the ecraseur, but these 
methods are unnecessary. If any hemorrhage should 
follow the operation, the cavity of the uterus should be 
packed with sterile gauze. 

Adenomyoma is a rare form of myoma of the uterus, 
which contains epithelial canals of the glandular type. 
Unlike the common fibromyoma, this tumor has no con- 
nective-tissue capsule and its structure cannot be well 
differentiated from the tissue of the surrounding uterine 
wall. 

Adenomyomata are of two varieties : in one variety the 
epithelial canals seem to be derived from the utricular 
glands ; in the other from the embryonal remains of the 
Wolffian body. 

In the first variety the tumor is situated in the pos- 
terior, anterior, or lateral uterine wall, and has the 
usual characteristics of a fibromyoma, except for the 
presence of glandular structures and the absence of a 
capsule. 

Adenomyomata, which are derived from the Wolffian 
body, develop in the posterior portion of a uterine horn, 
or less often in the tube, and when small, in the periph- 
eral layers of the muscular wall. The tumor may after- 
ward become interstitial or submucous. 
17 



258 A TEXT-BOOK OF DISEASES OF WOMEN. 

These tumors are of various degrees of hardness. They 
may be dense in consistence, in case the muscular tissue 
is in excess of the glandular, or they may be soft cystic 
tumors containing numerous distinct macroscopic cavi- 
ties. Telangiectatic adenomyomata also occur. 

The treatment of adenomyoma of the uterus is hyster- 
ectomy. 



CHAPTER XXI. 
HEMATOMETRA; HYDROMETRA; PYOMETRA. 

If there exists in the genital tract any obstruction that 
prevents the escape of menstrual blood, the uterus 
will become distended and the condition of hematometra 
will be present. If the retained fluid consists chiefly of 
the mucous secretion of the utricular glands, the condi- 
tion is described as hydrometra; or if suppuration has 




Fig. 135. — Hematometra. 

taken place, so that the uterus becomes distended with 
pus, the condition is called pyometra. 

The uterine walls may be very much attenuated by the 
distention, or the muscular coat may hypertrophy as the 
accumulation progresses. 

259 



260 A TEXT-BOOK OF DISEASES OF WOMEN. 

The cause of these conditions may be congenital or 
acquired atresia of any part of the genital tract. The 
symptoms usually appear after puberty. The menstrual 
period is accompanied by intense bearing-down pain in 
the region of the uterus. There is no appearance of men- 
strual blood. A round tumor may be felt in the hypo- 
gastrium. Examination will reveal the obstruction in 
the cervical canal. Sometimes the chief accumulation 
and distention occur in the cervix; in other cases the 
body of the uterus is chiefly affected. 

Distention of the Fallopian tubes, with the formation 
of hematosalpinx, hydrosalpinx, or pyosalpinx, often ac- 
companies old cases of hematometra. 

The treatment consists in relieving the obstruction 
and in maintaining the patulous condition of the genital 
tract. If the cervix is the seat of the obstruction, it 
should be punctured with a trocar and thoroughly dilated. 
It may be necessary to practise repeated dilatation in 
order to keep the canal open. 

The accompanying disease of the Fallopian tubes may 
persist after drainage of the uterus, and salpingo-oopho- 
rectomy or hysterectomy may be ultimately required. 



CHAPTER XXII. 
TUBERCULOSIS OF THE UTERUS. 

Tuberculosis of the uterus is not a very rare disease. 
In this respect it differs from tuberculosis of the cervix, 
which, as has already been said, is a most unusual site 
for the appearance of tuberculosis. Even in advanced 
cases of tuberculosis of the body of the uterus it is very 
rare that the condition extends below the internal os. 

Tuberculosis of the uterus is often found post-mortem 
in women who have died of phthisis or other form of 
tubercular disease. It has also been recognized during 
life, and operation has been performed for its relief. 

Tuberculosis of the uterus seems most frequently to be 
secondary to a tubercular lesion in some other part of the 
body. It often begins in the Fallopian tubes, and extends 
thence to the endometrium; or it may be primary in the 
endometrium, caused by infection through the genital 
tract. 

The disease first attacks the endometrium, and in the 
late stages extends to the muscular coat. 

Tuberculosis of the endometrium may occur in three 
forms — miliary tuberculosis, chronic diffuse tuberculosis 
(caseous endometritis), and chronic fibroid tuberculosis. 

Miliary tuberculosis of the uterus may be part of a 
general miliary tuberculosis. Typical miliary tubercles 
are found scattered throughout the endometrium, usually 
situated immediately beneath the epithelium (Fig. 136). 

Chronic diffuse tuberculosis is the most frequent form. 
The uterine cavity is filled with cheesy material. The 
mucous membrane is the seat of irregularly shaped ulcers 
and tubercles in various stages of development. When 
the disease has extended to the muscular coat of the 

261 



262 A TEXT-BOOK OF DISEASES OF WOMEN. 

uterus, the whole organ becomes considerably enlarged. 
Degeneration and softening of the uterine wall may be 



4 



v::v r 



1 5^*"* »«'"', 



( *¥% • 



Fig. 136. — Miliary tuberculosis of the endometrium and glandular endometritis 

(Beyea). 

so extensive as to cause rupture. The internal os may 
become closed, and a pyometra may be produced. 

Chronic fibroid tuberculosis of the endometrium seems 
to be the rarest form of the disease. A microscopic sec- 




Fig. 137. — Advanced fibroid tuberculosis of the endometrium (Beyea). 

tion of this form of tuberculosis is shown in Fig. 137. 
The endometrial tissue was almost entirely destroyed, 



TUBERCULOSIS OF THE UTERUS. 263 

and was replaced by a mass of typical miliary tubercles. 
There were no traces of glandular tissue. The tubercles 
were separated from each other by a very extensive small 
round-cell infiltration and a small amount of remaining 
stroma tissue. To the naked eye the endometrium did 
not appear to be diseased. 

Tuberculosis of the uterus may occur at any period of 
life. It is most often found between the twentieth and 
fortieth years. 

The symptoms of tuberculosis of the uterus are not 
at all characteristic. In the early stages they resemble 
those of non-tubercular endometritis. There is sometimes 
a very profuse leucorrhea, which may contain the charac- 
teristic cheesy material. The body of the uterus may be 
considerably hypertrophied. If the condition follows 
tuberculosis elsewhere, or if any form of genital tuber- 
culosis exists in the husband, the physician would be led 
to suspect tuberculosis of the uterus. 

The diagnosis can be made only by thorough curet- 
ting of the uterine cavity and the microscopic examina- 
tion of the tissue removed. The tubercle bacillus has 
not often been found, but the other microscopic appear- 
ances are frequently characteristic. In the case from 
which the section shown in Fig. 137 was taken the diag- 
nosis of tuberculosis of the endometrium was made by 
such curetting and examination. 

The treatment of tuberculosis of the uterus is hyste- 
rectomy. The operation is indicated in every case except 
those in which there is present in some other part of the 
bodv an incurable tubercular lesion. 



CHAPTER XXIII. 
INVERSION OF THE UTERUS. 

In inversion of the uterus this organ is turned partly 
or completely inside out. The condition usually results 
from childbirth or from the growth of an interstitial or 
polypoid tumor. 

There seem to be two factors that result in the pro- 
duction of inversion: a degeneration or atrophy of part 
of the uterine wall, and traction, as from the drag of a 
uterine polyp or of the umbilical cord. These causes 
may act together or independently. 

If a portion of the uterine wall has lost its strength or 
tonicity, it may be depressed toward the uterine cavity. 
The depression is increased by the traction of a tumor or 
of the umbilical cord. The inversion having been started 
in this way, may be rapidly increased by uterine contrac- 
tions. Emmet says that inversion usually takes place 
between the birth of the child and the delivery of the 
placenta. A consideration of the subject of acute inver- 
sion following labor belongs to obstetrics. It is very 
important that reduction should be accomplished im- 
mediately. The delay of a few hours greatly increases 
the difficulty of replacement. Emmet says: " The uterus 
is generally well contracted in twelve hours, and with 
many cases it would be then quite as difficult to effect a 
reduction as if a year had elapsed. ' ' 

If the placenta is still attached to the inverted uterus, 
it should be removed before reduction is attempted. In- 
version of the uterus when seen by the gynecologist is 
usually of the chronic form. It has existed for a few 
weeks or for several years. 

Various degrees of inversion are met with. Rarely 

264 



INVERSION OF THE UTERUS. 



265 



inversion of one horn of the uterus is seen. In the case 
of fibroid polyp there may be a slight depression of part 
of the uterine wall, resulting from local atrophy and 
traction. In other cases inversion of the fundus as far as 
the internal os exists. The most usual condition is one 
of complete inversion, in which the body of the uterus 
protrudes from the external os into the vagina (Fig. 138). 




Fig. 138. — Complete inversion of the uterus. 

The cervix may or may not be inverted. Sometimes the 
inversion is complicated by vaginal prolapse — or, rather, 
by inversion of the vagina — so that the whole genital 
tract becomes turned inside out and protrudes from the 
vulva. The exposed endometrium becomes congested 
and bleeds easily. Ulceration or gangrene may result. 
If the inversion is extensive, the Fallopian tubes and 
the ovaries are drawn in the cup formed on the upper as- 
pect of the uterus. Intestines or omentum may also lie 
in this cup. In cases of long standing the rim of the 
cup formed by the muscular cervix becomes very much 
contracted, and adhesions may take place between the 
peritoneal surfaces. These complications offer great, 
sometimes insurmountable, difficulty to reduction in old 
cases. 



266 A TEXT-BOOK OF DISEASES OF WOMEN. 

Inversion of the uterus is not a common disease. It is 
very rarely seen at the present day. 

By far the most frequent form is that which follows 
labor; it is much less often caused by fibroid polyp. It 
seems especially likely to occur in sarcoma of the uterus. 






m 



. 



yky*i 



'yM }> Q; 



J 



jKi 





Fig. 139. — Inversion of the uterus (Jeancons) : a, mons veneris; c, c, nym- 
phse; d, clitoris; e, external meatus; g, anterior lip of cervix; k, h, the internal 
surface of the uterus. 



The symptoms of chronic inversion are hemorrhage, 
discharge, backache, bearing-down pains in the pelvis, 
vesical disturbance, very pronounced anemia, and gen- 
eral physical weakness. Menstruation is very much in- 
creased in amount, and intermenstrual bleeding may 
occur after standing or on any physical effort. 

Inversion of the uterus very rarely exists without caus- 
ing serious symptoms. The majority of unrelieved cases 
end fatally from anemia, septicemia, or peritonitis. A 



INVERSION OF THE UTERUS. 26; 

few cases of spontaneous reduction and cure have been 
recorded. 

The diagnosis of recent inversion is very easy. The 
body of the uterus usually projects into the vagina, and 
the placenta may be found attached to it. The abdomi- 
nal hand fails to feel the rounded body of the uterus in the 
normal position, but in its place is a cup-shaped hollow. 

Chronic inversion if uncomplicated by other lesion — 
e. g. a uterine tumor — may also be readily recognized by 
careful examination. There are, however, a number of 
cases on record in which the inverted fundus uteri was 
amputated in mistake for a fibroid polyp. 

The diagnosis may be made by inspection, bimanual 
examination, and the uterine sound. 

In complete inversion, inspection shows a round tumor 
filling the vagina or protruding from the vulva. The 
tumor is covered with mucous membrane, perhaps ulcer- 
ated in places, and sometimes partly covered with strati- 
fied squamous epithelium, which has, as a result of irrita- 
tion, replaced the normal epithelium of the endometrium. 
It is of a deeper red color than a pedunculated fibroid. 
The tumor bleeds easily. In the only case of inversion 
seen by the writer the orifices of the Fallopian tubes 
could be determined. 

Digital examination reveals the rounded shape of the 
tumor and its soft character — softer than a fibroid polyp. 
The tumor may be so soft that it becomes flattened against 
the posterior vaginal wall. 

The tumor is found to be free on all sides except at its 
upper extremity, where there is a pedunculated attach- 
ment around which may be felt the more or less attenu- 
ated cervix. 

If the cervical canal be not obliterated by adhesion to 
the neck of the tumor, the finger may be passed upward, 
and will determine that the mucous membrane is reflected 
symmetrically all around on to the neck of the tumor. 

Unless the woman be fat, the abdominal hand will 
determine that the uterine body is not in its normal posi- 



268 A TEXT-BOOK OF DISEASES OF WOMEN. 



tion. In its place may be felt the cup-shaped portion of 
the inverted uterus. 

If the woman be fat, the rim of the cup may be felt 
by palpation through the rectum, the uterus being drawn 
down, if necessary, by a tape passed around the upper 
portion of the tumor. 

The sound passed around the neck of the tumor will 
show the diminished depth of the uterine cavity and the 
symmetrical reflection of the cervix on to the neck of the 
tumor. 

If the inversion be partial, the fundus lying still above 
the internal os, the difficulty of diagnosis becomes much 
greater. Examination under anesthesia may be necessary, 
when the cup-shaped depression on the top of the uterus 
may be detected, and dilatation of the cervix will enable 
the examiner to palpate the intra-uterine tumor. 

The differential diagnosis between inversion and ute- 
rine polyp is made by determining, in the latter condition, 
that the body of the uterus lies in its normal relationship 
to the cervix, and that the upper surface is not cupped. 

The sound usually passes to unequal distances around 
the neck of a fibroid polyp, unless it be situated symmet- 
rically in the centre of the fundus. The depth of the 
uterus in the case of uterine polyp is usually greater than 
two and a half inches, as a result of the hypertrophy that 
accompanies polypi. 

It is said that if the sound passes to a less depth than 
two and a half inches in the case of uterine polyp, ac- 
companying partial inversion of the uterus should be 
suspected. 

Treatment. — As I have already said, an inverted ute- 
rus should be reduced immediately after the accident 
occurs. If this is not done, the difficulties of reduction 
become very great. Until about fifty years ago, reduc- 
tion in chronic cases was considered to be impossible. A 
considerable variety of methods of reduction have been 
recommended. Some operators advocate reduction by 
the hands alone; others advise the assistance of instru- 



INVERSION OF THE UTERUS. 269 

ments; and others, again, the employment of continuous 
elastic pressure. 

The woman should be kept in bed for a few days before 
the operation. Saline laxatives should be administered. 
The parts should be prepared by vaginal injections of hot 
water in large quantity, administered three times a day. 
A large Barnes bag or colpeurynter rilled with air or 
water should be placed in the vagina for two or three 
days before the operation, in order to distend the genital 
tract sufficiently to admit the hand. In some cases the 
pressure of such a bag, applied for from one to eleven 
days, has itself effected reduction. At the time of oper- 
ation an anesthetic should be administered and the woman 
should be placed in the lithotomy position. The bladder 
should be emptied. 

The hand should be greased before introduction into 
the vagina. Emmet describes the method of reduction 
as follows: "My hand was passed into the vagina, and, 
with the fingers and thumb encircling the portion of the 
body close to the seat of inversion, the fundus was 
allowed to rest in the palm of the hand. This portion 
of the body was firmly grasped, pushed upward, and the 
fingers were then immediately separated to their utmost; 
at the same time the other hand was employed over the 
abdomen in the attempt to roll out the parts forming the 
ring, by sliding the abdominal parietes over its edge. 




Fig. 140. — White's repositor for inversion of the uterus. 

This manceuver was repeated and continued. At length, 
as the diameter of the uterine cervix and os was increased 
by lateral dilatation with the outspread fingers, the long 
diameter of the body of the uterus became shortened, 
and the degree of inversion proportionally lessened. 



2/0 A TEXT-BOOK OF DISEASES OF WOMEN. 



After the body had advanced well within the cervix, 
steady upward pressure upon the fundus was applied by 
the tips of all the fingers brought together." 

The reduction may be aided by the use of White's 
repositor (Fig. 140). This instrument consists of an 
india-rubber cup set on a curved iron staff which has at 
its other end a stout spiral spring. The cup is placed 
against the inverted fundus, and the spring against the 
body of the operator, who is thus enabled to maintain 
continuous pressure during the manipulations of his 
fingers. 

Reduction of chronic inversion by manual methods is 
a long and exhausting process, requiring sometimes three 

or four hours for its ac- 
complishment. It is ad- 
visable to have several as- 
sistants for mutual relief. 
It may be necessary to de- 
sist, and to repeat the ope- 
ration when the condition 
of the patient permits it. 
In case the reduction can 
be but partially accom- 
plished, or when, from 
any cause, the attempt at 
reduction has to be tem- 
porarily abandoned, the 
result of the work done may be preserved by a method 
of Emmet's of temporarily closing the cervix by suture 
(Fig. 141). This procedure not only prevents the com- 
plete inversion from returning, but the traction produced 
by stretching the cervix over the fundus itself favors 
reduction. 

Reduction by Continuous Elastic Pressure. — This 
method is employed after the manual method has failed, 
or it may be used primarily. As has been said, the 
gradual pressure of a colpeurynter has in several in- 
stances accomplished reduction. 




Fig. 141. — Emmet's method of retain- 
ing partially reduced inversion. 



INVERSION OF THE UTERUS. 



271 






The most efficient instrument for maintaining continu- 
ous pressure consists of a wooden cup set on a stem that 
extends out of the vagina. Pressure is made by firm 
elastic bands attached to the stem; these bands pass, two 
in front and two behind, to a broad abdominal bandage. 
The elastic pressure is maintained for from one to three 
weeks. 

The parts must be carefully watched for sloughing. 
The rim of the cup of the repositor should be covered 
with lint saturated with carbolized oil. The instrument 
should be removed and reapplied every day. 

The direction of pressure may be regulated by the 
tension of the elastic bands. 

Splitting the posterior lip of the cervix is sometimes a 
useful procedure in cases that have resisted other treat- 
ment. The cervix is split in the median line posteriorly; 
the body and fundus are replaced by taxis, and the in- 
cision is then closed by suture. 

If inversion accompany a uterine polyp, the tumor 
should be removed ; and if the inversion is not spontane- 
ously corrected, it must be reduced. 

If, after careful trial of conservative methods, reduc- 
tion of an inverted uterus is found to be impossible, the 
physician may be compelled to amputate the inverted 
portion or perform hysterectomy. 



CHAPTER XXIV. 
DISEASES OF THE FALLOPIAN TUBES. 

The review of a few facts about the anatomy of the 
Fallopian tubes will assist in the study of the diseases 
that affect these structures. 

The average length of the normal Fallopian tube is 4 
inches (10 centimeters). The tubes are often of unequal 
length, the difference sometimes being equal to 1 centi- 
meter. The length of the Fallopian tube is subject to 
considerable variation, and in some forms of ovarian dis- 
ease the length of the tube may be very much increased 

The uterine end of the tube varies in thickness from 
2 to 4 millimeters. The outer end varies from 7 to 10 
millimeters in thickness. 

The narrow uterine end of the tube is called the isth- 
mus. The outer end, of trumpet-shape, is called the 
ampulla. The canal of the tube is small. At the uterine 
end, or ostium internum, it will barely admit a bristle. 
Beyond the middle of the tube the canal gradually widens 
to the outer opening — the ostium abdominale. 

The ostium abdominale is surrounded by peculiar 
luxuriant folds of mucous membrane called fimbriae. 
The fimbriae are formed by the outward bulging of the 
exuberant mucous membrane. 

The Fallopian tube consists of three coats, the peri- 
toneal, the muscular, and the mucous. 

The peritoneal coat, which invests the tube for two- 
thirds of its circumference, is formed by the free bordei 
of the broad ligament, between the folds of which the 
Fallopian tube lies. Loose connective tissue attaches the 
peritoneal to the middle or muscular coat. 

2.72 



DISEASES OF THE FALLOPIAN TUBES. 273 

The muscular coat consists of unstriped muscular fiber 
which is continuous with that of the uterus. The mus- 
cular fibers are arranged in two layers, an outer longitu- 
dinal and an inner circular layer. 

The inner or mucous coat, which is continuous with 
the mucous membrane of the uterus, is covered with 
columnar ciliated epithelium. 









Fig. 142. — Section of the normal Fallopian tube near the uterine cornu (Beyea). 

In the outer portion of the tube the mucous membrane 
is thrown into longitudinal folds or plicae. These folds 
increase in thickness and in number as the ostium ab- 
dominale is approached. The difference in the degree 
of plication at the two ends of the tube is shown by 
Figs. 142, 143. The folds of mucous membrane project 
beyond the ostium to form the fimbriae. Iyike the rest 
of the mucous membrane, the fimbriae are covered by 
columnar ciliated epithelium. 

The peritoneal covering does not, as a rule, extend on 

18 



274 A TEXT-BOOK OF DISEASES OF WOMEN. 

to the fimbriae. It terminates by a sharp line which 
marks also the termination of the circular muscular fibers 
of the middle coat of the tube. The fimbriae are subject 
to great variation in number and in distribution. Some- 









% 






Fig. 143. — Section of the normal Fallopian tube near the abdominal ostium 

(Beyea). 

times the Fallopian tube has one or two accessory ostia 
in the vicinity of the usual opening. These accessory ostia 
are situated on the upper aspect of the tube and are sur- 
rounded by more or less luxuriant fimbriae. Occasionally 
a small pedunculated tuft of fimbriae is found on the 
outer portion of the tube (Fig. 144, B). In some cases 



DISEASES OF THE FALLOPIAN TUBES. 275 




Fig. 144. — Fallopian tube and ovary: A, accessory tubal end with an ostium; 
B, pedunculated tuft of fimbriae. 

there is an accessory tubal end supplied with an ostium 
(Fig. 144, A). 




Fig. 145. — Fallopian tube, ovary, and parovarium: a, hydatid of Morgagm; 
b, cyst of Kobelt's tube; c, Gartner's duct. 

Very often a small pedunculated cyst, about the size 
of a pea, is found attached to the fimbriae or to the outer 
aspect of the tube. 



276 A TEXT-BOOK OF DISEASES OF WOMEN. 

These cysts are called hydatids, or cysts of Morgagni. 
They are said to occur in about 8 per cent, of adults and 
in 20 per cent, of fetuses. They are not pathological. 

The cyst wall is composed of three coats: an external 
peritoneal coat; a middle muscular coat, arranged in two 
layers; and an inner mucous coat covered with columnar 
ciliated epithelium. The cyst contains a clear watery 
fluid. 

No distinct glands, such as are found in the cervix and 
the body of the uterus, have been observed in the Fallo- 
pian tubes. The mucous crypts formed by the folds of 
the mucous membrane are probably glandular in character 
and secrete an albuminous fluid. 

INFLAMMATION OF THE FALLOPIAN TUBES, OR SALPIN 

QITIS. 

Inflammation is the disease that most usually affects 
the Fallopian tubes. The condition is, as a rule, second- 
ary to endometritis, the mucous membrane of the tubes 
becoming inflamed by direct extension from the mucous 
membrane of the uterus. 

The causes of salpingitis are as numerous as those of 
endometritis. The most common causes of salpingitis are 
sepsis and gonorrhea. 

Any form of inflammation of the endometrium may 
extend to the Fallopian tubes, but the septic and the 
gonorrheal forms of endometritis are especially virulent, 
and it is the rule in these diseases that the tubes are 
affected. 

The various forms of glandular and interstitial endo- 
metritis that have already been described, and which are 
due to subinvolution, laceration of the cervix, uterine 
displacements, fibroid tumors, etc., may exist for a long 
time without producing any perceptible disease of the 
tubes. In sepsis and gonorrhea, however, the tubes be- 
come very quickly affected after the uterine cavity has 
been invaded, and for this reason these forms of endome- 
tritis excite the greatest apprehension. 



DISEASES OF THE FALLOPIAN TUBES. 277 

Like inflammation of other structures, salpingitis may 
be either acute or chronic. 

Acute Salpingitis. — In the first stages of acute sal- 
pingitis the disease is confined to the mucous membrane 



: 



V 




:■■■ • 

mm 



Fig. 146. — Acute septic salpingitis : section about the middle of the tube 

(Beyea). 

of the tube. It very quickly extends thence, however, 
to the muscular and peritoneal coats, which become infil- 
trated with embryonic cells characteristic of the early 
stages of inflammation (Fig. 146). 

If the tube is laid open, the mucous membrane is found 



278 A TEXT-BOOK OF DISEASES OF WOMEN. 

covered with a mucopurulent secretion. The whole 
tube is soft, succulent, and friable. The friability is 
such that the tube may readily be ruptured by bending. 
The fimbriae are swollen and congested. A drop of pus 
is often seen exuding from the ostium abdominale. 

In acute salpingitis the tube may become very quickly 
(in a week or ten days) enlarged to the size of the index 
finger or the thumb. 

The condition that has been described is that found in 
the severe cases of acute salpingitis, the result of gonor- 
rhea or of sepsis after labor. Opportunity is afforded to 
examine such cases when the woman has been subjected 
to celiotomy, or at the post-mortem when the woman has 
died of acute peritonitis or sepsis. 

It is probable that a good many cases of acute salpin- 
gitis undergo resolution, and that the tube is restored to 
its normal condition. 

It is also probable that milder forms of acute salpin- 
gitis occur — cases in which the disease is limited to the 
mucous membrane and is merely catarrhal in character, 
there being no pus, but a hypersecretion of mucus from 
the tube-lining. Such cases, however, recover or pass 
into a chronic form of simple catarrhal salpingitis ; and 
the diagnosis made by a study of the subjective and ob- 
jective symptoms cannot be confirmed by operation or 
autopsy. 

Resolution with perfect restoration of the Fallopian tube 
to its normal condition is, of course, always to be hoped 
for. In some cases a few fine peritoneal adhesions be- 
tween the tube and neighboring structures — such as the 
ovary, the uterus, the anterior or the posterior surfaces 
of the broad ligament, or a loop of intestine — may result 
before resolution takes place, and persist after all other 
traces of inflammation have disappeared. In other cases 
cure may result, after a greater or less degree of perma- 
nent damage has been done to the abdominal ostium of 
the tube, by the shrinking and distortion or crumpling of 
the fimbriae. Such indications of an old, cured attack 



DISEASES OF THE FALLOPIAN TUBES. 279 

of salpingitis are not infrequently seen during celiotomy 
for other conditions. 

When resolution and cure do not occur, a speedy fatal 
result may take place by direct extension of the infection 
from the tube to the general peritoneum, with the pro- 
duction of general peritonitis. Between this extreme 
and the mild forms of very localized peritonitis, marked 
by a few harmless adhesions, all degrees may exist. 
Sometimes a local accumulation of pus occurs in the 
pelvis, walled off from the general peritoneum by rapidly 
formed adhesions. In other cases a tubal abscess is 
quickly formed by inflammatory closure of the abdom- 
inal ostium and distention of the tube with pus; or the 
cellular tissue of the broad ligament may become in- 
fected, and the abscess may originate there. And, 
finally, if the woman escape these dangers, one or other 
of the various forms of chronic salpingitis may result, 
and render her a lifelong invalid. 

Chronic Salpingitis. — Salpingitis is usually seen in 
the chronic form. An acute primary salpingitis must 
not be confounded with an acute attack of inflammation 
or with an acute exacerbation in an old chronic case. It 
is rare that acute gonorrheal salpingitis is seen. The 
disease is usually subacute or chronic from the begin- 
ning, as are many of the other manifestations of gonor- 
rhea in woman, like gonorrheal cervicitis and endometri- 
tis. The most frequent form of acute salpingitis met with 
is the septic variety, which occurs as a result of septic 
infection after a criminal abortion, a miscarriage, or a 
labor. It is usually complicated by severe septic endo- 
metritis, peritonitis, or general sepsis. 

The lesions found in chronic salpingitis are numerous. 
The simplest form of the disease is the chronic catarrhal 
salpingitis, in which the pathological changes are con- 
fined to the mucous membrane of the tube. The mus- 
cular and peritoneal coats are not affected. The ostium 
abdominale remains open and is of the normal shape. 
The mucous membrane is congested. The folds of 



280 A TEXT-BOOK OF DISEASES OF WOMEN. 

mucous membrane, or the plicae, are hypertrophied from 
gradual infiltration of inflammatory products. The tube 
may become somewhat enlarged and more tortuous than 
normal. If the inflammatory condition extends to the 
middle or muscular coat of the tube, the interstitial 
form of salpingitis is produced. The wall of the tube 
becomes thicker and harder. The microscope shows an 
increased amount of connective tissue in the tube- wall. 

As chronic salpingitis progresses the ciliae of the lining 
cells disappear. 

If the disease extends through the peritoneal coat, in- 
flammatory adhesions take place between the tube and 
neighboring structures. The tube is often found adherent 
to the posterior aspect of the uterus, the broad ligament, 
or the ovary. 

The most usual seat of adhesions is about the abdominal 
ostium. Adhesions here are caused by leakage or escape 
of septic material into the peritoneal cavity. The leak- 
age is slow, and the gradually formed adhesions in time 
close the ostium by gluing it to adjacent structures, so 
that further escape of tubal contents by this opening is 
stopped. 

If, in such a case, the tube is freed from its adhesions, 
the fimbriae will be found in the normal position with the 
ostium abdominal e open. 

The usual method of closure of the distal end of the 
Fallopian tube is by another process. It takes place as 
follows: When the inflammation reaches the muscular 
coat of the tube, this coat becomes lengthened and ex- 
tends beyond the fimbriae, which apparently retract and 
become invaginated in the tube. The opening of the 
tube, instead of being flaring with protruding, diverg- 
ing fimbriae, becomes rounded and narrow (Fig. 147). 
The fimbriae become drawn farther into the tube until 
they appear to be directed inward instead of outward. 
The ostium becomes narrower, and more rounded, 
until the edges finally meet and unite by peritoneal 
adhesions. 



DISEASES OF THE FALLOPIAN TUBES. 



28l 



Tubes representing all stages of this process of closure 
are often found in operating for inflammatory disease. 

Closure of the abdominal ostium by any method is to 
be viewed as a conservative process. It prevents leakage, 
through this channel, of septic material, and consequently 
diminishes the danger of peritonitis. 

When the abdominal ostium has become closed, the 
tubal contents and secretions may have a sufficient 
passage for escape by the isthmus into the uterus, and 
no further changes take place beyond slow infiltration 




Fig. 147. — Salpingitis with partial inversion of the fimbriae. 



and degeneration of the tube-walls. The tube may be- 
come much hypertrophied, not from distention of the 
lumen, but as the result of simple inflammatory infiltra- 
tion of the mucous and muscular coats, and may attain 
the size of the thumb. The walls may become much 
degenerated, soft, and friable, so that the tube may easily 
be cut through by a ligature or may be broken by bending. 
The whole tube may become much elongated and very 
tortuous, reaching a length of six or eight inches. The 
isthmus of the tube, or the portion in immediate relation 
to the uterus, is usually least affected. The whole tube 
may become much hypertrophied, and yet the isthmus 
will remain approximately of its normal size. In other 



282 A TEXT-BOOK OF DISEASES OF WOMEN. 

cases, however, the disease extends throughout the whole 
length of trie tube into the uterine horn, and the degen- 
eration of the tube may be such that it may readily be 
broken off at its junction with the uterus. 

If, after the ostium abdomiuale has been closed, any- 
thing occurs to obstruct the escape of the tubal contents 
into the uterus, cystic distention of the tube will take 
place. Such obstruction may be produced by swelling 
of the mucous membrane in the narrow isthmus; by cica- 
tricial contraction; or by a sharp flexure in any part of 
the tortuous tube. Sometimes there are two or more 
distended portions of the same tube. 

When the tube is distended with pus, the condition is 
called a pyosalpinx; when distended with a watery fluid, 
a hydrosalpinx; and when distended with blood, a he- 
matosalpinx. 

Tubal cysts of this kind may attain large size, in some 
cases equal to that of the fetal head. 

The shape of the tube becomes much altered. The 
greatest distention is at the distal portion, so that the 
tube assumes a pear-shape. The lower portion of the 
tube is restrained by the mesosalpinx and the tubo-ova- 
rian ligament, so that as the tube increases in length the 
upper portion appears to outgrew the lower, and a retort- 
shaped tumor results, or the tube may become tortuous 
and folded upon itself. 

As the tube enlarges the layers of the mesosalpinx 
may become separated, and the tube burrows between 
them until it is brought into immediate contact with the 
ovary, and the retort-shaped tumor appears with the ovary 
lying in the concave portion. 

In some cases the ovary and the tube become adherent 
by peritoneal adhesions, and the mesosalpinx, which is 
wrinkled and folded between them, may be restored by 
separation of the adhesions. 

In other cases the mesosalpinx itself becomes much 
thickened by inflammatory infiltration, and keeps the 
tube and ovary separated. 



DISEASES OF THE FALLOPIAN TUBES. 283 

In chronic salpingitis the inflammatory process usu- 
ally in time extends to the ovary, and some of the forms 
of chronic ovaritis are produced. 

The capsule of the ovary becomes thickened, and rup- 
ture of the ripe ovarian follicles is prevented. Small 
cysts throughout the ovary are formed in this way. Two 
or more cysts may become converted into one cavity by 
absorption of the intervening walls, so that cystic spaces 
of larger size, equal to that of a duck-egg, may result. 
Such cysts may become infected by pyogenic organisms 
from the tube, and an ovarian abscess is produced. 

Tubo-ovarian Abscess. — If the tube is brought into 
immediate contact with the ovary, either by agglutina- 




Tubo-ovarian abscess. 



tion of the fimbriated end to the surface of the ovary, or 
by adhesion of the side of the tube to the ovary, or by 
burrowing between the layers of the broad ligament, the 
tissue intervening between the cavity of the tube and 
the cyst of the ovary may be absorbed or perforated, and 
the two cavities will be thrown into one, forming a 
tubo-ovarian abscess or a tubo-ovarian cyst (Fig. 148). 
The opening between the tubal and ovarian portions of 
the cyst does not usually correspond to the abdominal 



284 A TEXT-BOOK OF DISEASES OF WOMEN. 

ostium of the tube, but may be an adventitious opening 
in the side of the tube (Fig. 148). 

Pyosalpinx. — When the Fallopian tube is distended 
with pus or with other fluid, its walls gradually become 
thinned. In this respect the Fallopian tube differs from 
the body of the uterus, in which a hypertrophy of the 
muscular coat usually takes place, under the influence of 
distention from the presence of retained fluid within it. 

This gradual thinning of the tube-wall predisposes to 
rupture or leakage and the escape of the contents into 
the abdominal cavity. A pyosalpinx often becomes ad- 
herent to the rectum, the small intestine, or the bladder. 
The wall of the intestine or the bladder becomes perfor- 
ated, and the pus is discharged in this way. It seems 
probable that in some unusual cases the obstruction in 
the lumen of the tube is temporarily overcome, and that 
evacuation takes place through the uterus, followed by 
refilling of the tube. This, however, is a very unusual 
occurrence, and is not frequent, as is assumed by some 
writers. The evidence of such discharge is based only on 
clinical observation. There is no good pathological evi- 
dence of such an occurrence. It is probable that in most 
of the reported cases the purulent or watery discharge 
which escaped in a sudden gush was derived from, and 
had been retained in, the body of the uterus. 

The pus of pyosalpinx varies greatly in character. In 
the early stages of the disease it is actively septic and 
contains a variety of micro-organisms. 

These organisms are the gonococcus, streptococcus, 
staphylococcus, the bacillus coli communis, the tubercle 
bacillus, and the pneumococcus. 

In the later stages, however, these organisms become 
inert, die, and disappear, so that in the majority of cases 
of chronic pyosalpinx the pus is found to be bacterio- 
logically sterile. Observation on this subject made 
by a number of investigators shows that out of 133 
cases of acute and chronic suppuration of the uterine ap- 
pendages in which the pus was examined bacteriologi- 



♦ 



DISEASES OF THE FALLOPIAN TUBES. 285 



l 



cally, no organisms whatever were found in 82 cases ; in 
other words, the pus was sterile in about 61 per cent, of 
the cases. The pyosalpinx in time, therefore, becomes 
inert so far as any active inflammatory action is concerned, 
and resembles a chronic abscess in other parts of the body. 
Active inflammatory action may, however, be excited at 
any time, as in other chronic abscess, by a new infection, 
septic organisms entering the abscess by way of the ute- 
rine cavity, an adherent loop of intestine, or the bladder. 
The woman will then have an attack of acute septic in- 
flammation in the old pyosalpinx, and will be exposed to 




Fig. 149. — Hydrosalpinx, showing complete inversion of the fimbriae. 

the various dangers that were imminent during the pri- 
mary acute stages of the disease. 

It seems probable that if the woman survive the dan- 
gers to which she is exposed from a pyosalpinx, the 
tumor may in time become converted into a hydrosal- 
pinx. The solid constituents of the fluid become ab- 
sorbed or deposited upon the cyst- walls, and a clear 
watery fluid remains. In hydrosalpinx the recesses of 
the tube are often found to contain cheesy material and 
cholesterin — remnants of the old purulent accumulation. 
The tubo-ovarian cyst is formed in this way from a former 
tubo-ovarian abscess. 

Hydrosalpinx. — The fluid in a hydrosalpinx may be 



286 A TEXT-BOOK OF DISEASES OF WOMEN. 

colorless, slightly yellow, or brownish or chocolate 
colored from the presence of blood. As the accumula- 
tion increases, the walls of the cyst atrophy and become 
very thin. The epithelium and the mucous membrane 
atrophy and in time disappear, until nothing but a thin- 
walled transparent cyst remains (Fig. 149). The cyst- 
wall in hydrosalpinx is always thinner and more trans- 
parent than that in pyosalpinx. On the inner wall of 
the cyst delicate ridges corresponding to the plicae or 
folds of mucous membrane may be traced. There may 
often be discovered, at the distal end of the retort-shaped 
tumor, a slight depression that marks the position of the 
abdominal ostium, while upon the inner aspect of this 
depression may be found the remains of the invaginated 
fimbriae. The size of the tube in hydrosalpinx varies 
from that of the little finger to a tumor as large as the 
fetal head. Large hydrosalpinx tumors are very unusual, 
because the fluid probably leaks slowly through the thin 
cyst-wall, and because the secreting surface of the cyst 
becomes destroyed by pressure. The fluid from a hydro- 
salpinx is sterile, unirritating to the peritoneum, and is 
readily absorbed. The cyst may rupture spontaneously 
or as the result of some slight accident; the fluid will be 
absorbed by the peritoneum, and only the shrivelled, 
atrophied sac will remain. In old cases of this kind the 
Fallopian tube is represented by an impervious cord. 
Such specimens have often been found in old prostitutes 
who have survived the dangers of their calling. 

Hematosalpinx. — True hematosalpinx, a closed Fal- 
lopian tube distended with blood, is a rare condition. 
Tubal pregnancy is the usual cause of an accumulation 
of blood in the Fallopian tube, but the term hematosal- 
pinx should not be applied to this condition. True 
hematosalpinx occurs when, from any cause, hemorrhage 
takes place into a tube that had previously been closed 
by inflammatory action. Such an accident may be caused 
by traumatism or by torsion of the pedicle of a tubal cyst. 
Slight hemorrhages of this kind occur in pyosalpinx and 



DISEASES OF THE FALLOPIAN TUBES. 287 

in hydrosalpinx, and cause the brownish discoloration 
that is sometimes seen in the contents of these tumors. 

The various forms of inflammatory disease of the tubes 
that have been described under names which designate 
the gross appearance of the disease are all really but dif- 
ferent manifestations of the same primary condition. 
Gonorrheal or septic infection may produce any of the 
forms of tubal disease that have been mentioned. Inter- 
stitial salpingitis without closure of the ostium, pyosal- 
pinx, hydrosalpinx, hematosalpinx, tubo-ovarian abscess, 
etc. are not distinct diseases, but are different manifesta- 
tions of the same disease, representing different stages of 
progress or different methods of development. Several 
of these different forms are often found in the same 
woman. On one side there may be a hydrosalpinx, on 
the other a pyosalpinx, both caused by a primary chronic 
gonorrhea; the distal end of one tube may be distended 
by a clear watery fluid, forming a hydrosalpinx, while the 
isthmus may be distended with pus, forming a pyosal- 
pinx; a hematosalpinx may be formed on one side, while 
a tubo-ovarian abscess exists on the other; and so through 
a great variety of combinations. 

Pyosalpinx with active septic contents represents the 
early stages of tubal disease, or it represents a chronic 
condition in which reinfection has occurred. Pyosalpinx 
with sterile pus is like a chronic abscess anywhere else, 
and represents a chronic form of salpingitis that had been 
active and purulent in the beginning. Hydrosalpinx 
represents the disease less violent and septic in the begin- 
ning, and slow in progress; or it represents the last stages 
of an old pyosalpinx ; while, finally, hematosalpinx rep- 
resents a condition of salpingitis in which some accident 
has befallen the cystic tube and caused hemorrhage into 
its cavity. 

The description given shows the progress, the dangers, 
and the terminations of salpingitis. 

The disease is caused by extension of inflammation 
from the endometrium. The usual causes of this inflam- 



288 A TEXT-BOOK OF DISEASES OF WOMEN. 

mation are gonorrhea, or infection after a criminal abor- 
tion, a labor, or a miscarriage. The gonorrheal salpin- 
gitis is usually slow or insidious from the beginning. 
The symptoms of the disease are often not troublesome 
until many months after the primary gonorrheal infec- 
tion. The closure of the tube is slow, and it is some- 
times not until the tube becomes distended with pus that 
the woman experiences much suffering and is placed in 
imminent danger. There are cases, however, of acute 
gonorrheal salpingitis in which the disease is virulent 
and active from the beginning. Infection may traverse 
the tube, reach the peritoneum through the open ostium, 
and produce general peritonitis within a few days of the 
primary attack of gonorrhea. In such cases it is prob- 
able that the infection is a mixed one, other organisms 
accompanying the gonococcus. In other cases the ab- 
dominal ostium becomes quickly closed and a gonorrheal 
tubal abscess is rapidly formed. 

The septic variety of salpingitis, as has already been 
said, is more frequently acute from the beginning. With- 
in ten days or two weeks after a criminal abortion, or after 
a miscarriage or labor, a large tubal abscess may be 
formed; or the septic organisms may pass through the 
tube before the ostium has been closed, and produce with- 
in a few days a general fatal peritonitis. 

On the other hand, septic salpingitis is often slow, a 
mild attack of puerperal sepsis being the beginning of 
years of invalidism, of gradually increasing suffering, 
until gross tubal disease is produced. 

The slowest forms of salpingitis are those that result 
from chronic endometritis, such as accompanies subinvo- 
lution, laceration of the cervix, retro-displacements, or 
uterine fibroid. Simple catarrhal salpingitis is often found 
in these diseases; or the abdominal ostium may be closed, 
and a small hydrosalpinx will be present; or the isthmus 
may be sufficiently open for drainage, and no tubal dis- 
tention result. Hydrosalpinx is very often found with 
uterine fibroids. 



DISEASES OF THE FALLOPIAN TUBES. 



289 



Cancer of the cervix or the body of the uterus is a fre- 
quent cause of salpingitis, of hydrosalpinx, and of pyo- 
salpinx. The endometrial inflammation secondary to the 
cancer extends into the tubes. 

The progress of salpingitis is beset with danger. 

At any time a pyosalpinx may rupture and a rapid fatal 
peritonitis result. Unusual effort, vaginal examination, 
or slight operations upon the cervix or body of the ute- 
rus may cause this accident. Not infrequently, such 




FlG. 150. — Chronic salpingitis with general adhesions of tubes, ovaries, and 

uterus (Bandl). 



rupture has been produced by even gentle bimanual ex- 
amination. I have seen a fatal peritonitis occur from 
rupture of a pyosalpinx during the replacement of a pro- 
lapsed uterus. 

For this reason the operator should always determine 
by careful examination the presence or absence of tubal 
disease in every case before performing any of the minor 
gynecological operations or manipulations, such as tra- 
chelorrhaphy or the replacement of a retroverted uterus. 

19 



290 A TEXT-BOOK OF DISEASES OF WOMEN. 

Purulent disease of trie tubes is a contraindication to all 
such procedures, unless an immediate subsequent celiot- 
omy is to be performed. Great care must be exercised 
in any of the less dangerous forms of salpingitis. In 
any case of salpingitis, however mild, an acute attack 
may be excited by reinfection or by rough manipulation. 
Rupture into the peritoneum is not the only danger to 
which the woman is exposed in salpingitis. The gradu- 
ally formed adhesions in the pelvis impede the motion of 
the pelvic intestines and may cause intestinal obstruc- 




Fig. 151. — Chronic salpingitis: both Fallopian tubes are closed and adherent. 



tion. Obstruction of the ureters has occurred from pel- 
vic inflammation. The Fallopian tube may discharge 
its contents through the bladder and produce violent cys- 
titis, or it may discharge through the rectum or intestine, 
or adhere to the side of the vagina and discharge through 
this channel; or it may be evacuated through the abdom- 
inal parietes. Such fistulous openings rarely, if ever, 
close spontaneously and permanently. Temporary clos- 
ure may occur, but the tube will refill and discharge as 
before. 

Fistulse of this kind persist for many years, becoming 



DISEASES OF THE FALLOPIAN TUBES. 291 

seats of tuberculosis or exhausting the woman by the 
continuous suppuration. 

If the patient escape these dangers, the disease may 
become quiescent. Some of the less dangerous forms of 
salpingitis are produced, until finally, when the woman 
has reached middle life, a hydrosalpinx remains, or an 
adherent, atrophied, cord-like remnant of the tube. 
Though then freed from the various'dangers that had 
threatened her life, she is not restored to health, but 
remains a suffering invalid. 

Salpingitis may be unilateral or bilateral. It is more 
likely to be unilateral in the acute cases than in the 
chronic, for, as the primary focus of the disease exists in 
the body of the uterus, it will extend in time to the sec- 
ond tube in case only one had at first been involved. If 
the endometrial disease is cured before the second tube 
has been attacked, the salpingitis may remain unilateral. 
Double salpingitis is especially likely to occur in those 
diseases of the endometrium that are difficult or impos- 
sible to eradicate — diseases like chronic gonorrhea, where 
the infection lurks in the distal ends of the utricular 
glands and defies our methods of treatment. Operators 
have repeatedly removed a unilateral pyosalpinx, leaving 
the second tube apparently perfectly healthy, and yet, 
after the lapse of a few months, a second operation has 
been necessary for the relief of a similar pyosalpinx on 
the other side. 

Symptoms of Acute and Chronic Salpingitis. — The 
symptoms of acute salpingitis are usually obscured by 
the accompanying symptoms of endometritis, ovarian 
congestion and inflammation, and localized peritonitis. 
The woman complains of pelvic pain and tenderness, 
which are most severe in one or both ovarian regions. 
There are elevation of temperature and rapid pulse. The 
knees are often drawn up as in peritonitis. 

Bimanual examination reveals marked tenderness upon 
pressure in the vaginal fornices. There is an indistinct 
sense of fulness in the region of the tubes. If the pelvic 



292 A TEXT-BOOK OF DISEASES OF WOMEN. 

peritoneum and cellular tissue are involved, the whole 
vaginal vault will feel full and resistant. The tissues 
lying to the sides and behind the uterus are thickened 
and resistant. If the woman is thin and there is not 
much surrounding inflammation, it is sometimes possible 
to palpate the enlarged tender tube between the vaginal 
finger and the abdominal hand. Usually, however, the 
tenderness is too great to permit this. The tube, from 
its increase in weight, may fall below its normal level, 
and may be felt lying behind the uterus in Douglas's 
pouch. 

Usually, in cases of acute salpingitis, the examiner is 
obliged to content himself with the determination of an 
indistinct fulness and marked tenderness in the region of 
the Fallopian tubes. 

Before the true pathology of salpingitis was known 
these cases were described as pelvic peritonitis or pelvic 
cellulitis. It was supposed that the inflammation in- 
volved the peritoneum of the pelvis or the cellular tissue 
of the broad ligaments. It is true that this is often the 
case, and that inflammation of these structures accom- 
panies the salpingitis, but it is the tubal inflammation 
which is the primary disease. 

The most pronounced symptom of chronic salpingitis 
is pain. The pain is referred to one or to both ovarian 
regions as the disease is unilateral or bilateral. It is due 
not only to the salpingitis, but to the accompanying ova- 
ritis. The pain is continuous. It is relieved by the re- 
cumbent posture, and is increased whenever the woman 
is upon her feet or is performing any work. The pain 
is increased by a jolt or sudden movement, by defecation, 
often by urination and by coitus. The pain during co- 
itus, from direct pressure, is often so great that marital 
relations are abolished. I have seen a woman with sal- 
pingitis who was obliged to take a dose of morphine 
before every act of defecation. The pain from the jolt- 
ing of a carnage often renders riding impossible. 

The pain is dull and aching in character or sharp and 



DISEASES OF THE FALLOPIAN TUBES. 293 

lancinating. It may extend down the anterior aspect of 
the thighs. 

The pain is very much worse at each menstrual period. 
All the genital structures become congested and swollen 
at this time, and such phenomena, occurring in the ad- 
herent inflamed tubes and ovaries, often cause unbear- 
able pain. The dysmenorrhea in salpingitis is usually 
very characteristic. It begins several days — sometimes a 
week — before the bleeding appears. It starts in one or 
both ovarian regions, and radiates thence throughout the 
pelvis and down the thighs. It will be remembered that 
the dysmenorrhea of anteflexion begins only a few hours 
before the bleeding — that the pain is usually situated in 
the center of the lower abdomen, in the region of the 
uterus, is expulsive in character, and is relieved when 
the bleeding has become well established. 

The dysmenorrhea of salpingitis usually lasts through- 
out the whole of the period. 

The pain of salpingitis persists throughout the whole 
course of the disease. It is common to all forms of sal- 
pingitis, and seems to bear no relation to the gross cha- 
racter of the lesions of the tubes. The pain and the 
dysmenorrhea are often as marked in a case of salpingitis 
without cystic distention as in a case of large pyosalpinx. 

The pain persists after the dangerous stages of the dis- 
ease have been passed. Relief begins only with the 
cessation of menstruation, when general atrophy takes 
place in the genital organs. 

The pain of salpingitis is often obvious from the ex- 
pression and the posture of the woman. She walks with 
the body slightly flexed forward; she sits down gently 
upon a chair; she protects herself, by support with the 
hand, from the jolting of a carriage or a car. 

The woman frequently suffers with marked exacerba- 
tions of the pain, which occur independently of the men- 
strual periods, and are caused by leakage from the tube 
and the resulting local peritonitis. The woman often 
describes such attacks as attacks of "inflammation of the 



294 A TEXT-BOOK OF DISEASES OF WOMEN. 

bowels." They occur usually during the early stages of 
the disease. Each attack, if survived, results in a more 
perfect closure of the ostium abdominale, and diminishes 
the risk of subsequent attacks. At these times all the 
symptoms of local peritonitis are present: elevated tem- 
perature, rapid pulse, local or general distention, and 
tenderness. In any case of pyosalpinx or of old chronic 
salpingitis close questioning of the patient will elicit a 
history of this kind. 

Acute attacks of pain, fever, and other disturbance 
also occur in cases of chronic salpingitis from acute re- 
infection of the diseased tube. The disease may have 
been quiescent for a long time, and yet active reinfection 
may take place by way of the uterine cavity or by the 
passage of the colon bacillus through an adherent intes- 
tinal wall; or infection may occur through an adherent 
bladder. 

Salpingitis is usually accompanied by menorrhagia. 
It is impossible to determine how much of this is to be 
attributed to the tubal disease. There is always an ac- 
companying endometritis which is sufficient to account 
for it. 

Sterility is the rule in cases of salpingitis. The disease 
of the mucous membrane and the destruction of the ciliae 
render the passage of the ovum into the uterus difficult. 
For this reason tubal pregnancy may occur in salpingitis, 
impregnation and attachment of the ovum taking place 
within the tube. Inflammation of the ovary, which pre- 
vents the rupture of the ripened ovarian follicles, is an- 
other cause of the sterility. When the abdominal ostia 
are closed absolute sterility is present. 

In chronic salpingitis the condition of the Fallopian 
tubes is revealed by bimanual examination. The tube 
usually falls below its normal level, and may be felt by 
the vaginal finger lying beside the uterus, or behind it, 
in Douglas's pouch. By careful palpation the connection 
of the tubal tumor with the uterus may be traced. Bi- 
manual examination is most satisfactory in the quiescent 



DISEASES OF THE FALLOPIAN TUBES. 295 

stages of the disease. During an exacerbation or during 
one of the acute attacks of inflammation the tenderness 
prohibits thorough palpation, and the surrounding inflam- 
matory infiltration masks the condition of the tube. The 
tube may be felt as a hard cord, or as a cystic tumor with 
the ovary lying in its concavity, or as a tortuous, sausage- 
shaped mass. 

In old chronic cases the tube and ovary may be felt as 
a hard, knot-like mass adherent to the side of the uterus 
or coiled about the cornu (Fig. 151). 

In nearly every case the isthmus is rendered hard and 
cord-like by inflammatory infiltration. This indurated 
condition of the isthmus is a feature of tubal disease that 
is usually readily determined, and it is of decided diag- 
nostic value. The connection, by such a cord, of the 
mass felt in the pelvis with the uterine cornu is the 
most valuable proof that the tumor is tubal in character. 

Diagnosis. — The diagnosis of chronic disease of the 
Fallopian tubes must be made from a study of the history, 
the symptoms, and by physical examination. 

The history is always of value. Careful questioning 
will usually show that the ovarian pain dates from a 
criminal abortion, from an attack of fever after a miscar- 
riage or labor, or from a suspicious coitus. Women who 
have been infected with chronic gonorrhea by their hus- 
bands attribute the origin of the disease to their mar- 
riage. The woman will often say that for some days 
after marriage she suffered with irritation and burning 
of the external genitals, with dysuria, perhaps with a 
slight vaginal discharge, and that after this, very gradu- 
ally, the ovarian pain developed. She may have had one 
child or a miscarriage, but with this exception is usually 
sterile. 

The history of attacks of local peritonitis, confining 
the women to bed for several days or weeks, can also usu- 
ally be obtained. 

The character and the situation of the pain and the 
character of the dysmenorrhea usually point strongly to 



296 A TEXT-BOOK OF DISEASES OF WOMEN. 

salpingitis. The physical examination is not by any 
means always satisfactory. The small flaccid tubal tu- 
mors are often difficult to palpate, especially in fat 
women, and the gross forms of the disease may be ob- 
scured by surrounding adhesions and inflammation. The 
examination, however, when taken in connection with 
the history and the symptoms, will usually enable one to 
make the diagnosis. Inflammatory tumors in the female 
pelvis are very generally tubal in origin. 

It is difficult to estimate the mortality of salpingitis. 
It is certainly a frequent cause of death — not only im- 
mediately, by some of the acute accidents that may occur, 
but as a result of gradual exhaustion from prolonged sup- 
puration. Acute salpingitis, and the purulent forms of 
the disease, should always be viewed with anxiety. As 
appendicitis is the usual cause of peritonitis in man, so is 
salpingitis the usual cause of this disease in the woman. 
In every case of peritonitis in a woman, therefore, care- 
ful examination of the pelvic organs should be made. 

Salpingitis is an exceedingly common disease. It oc- 
curs in all classes of society, but most frequently in the 
lower walks of life. Salpingitis is the rule in prostitutes, 
and in them is caused by gonorrhea or by septic infection 
at criminal abortion. 

Treatment. — The treatment of acute salpingitis in its 
early stage should be expectant: absolute rest in the 
recumbent position, vaginal douches of a gallon of hot 
sterile water (ioo°-iio° F.) two or three times a day, 
small doses of saline purgatives (Rochelle salts, <5ss-3J 
every one or two hours) until mild purgation is produced, 
should be prescribed, and should be continued as re- 
quired. Relief of pain is afforded by hot fomentations 
over the lower abdomen. It is best to administer no 
opium, as it is very important to watch these cases closely, 
and the symptoms that demand operation might be 
masked by the administration of an anodyne. Examina- 
tions should be made with great care and gentleness, and 
no oftener than is necessary to determine the progress of 



DISEASES OF THE FALLOPIAN TUBES. 297 

the disease. If the patient is progressing satisfactorily, 
repeated examinations are contraindicated. 

A chill followed by a rapid high elevation of tempera- 
ture (io5°-io6° F.) is often caused by even gentle manip- 
ulation of the upper organs of generation in cases of 
acute inflammation. 

The case must be watched carefully and continuously. 
In the gonorrheal and septic forms of the disease there is 
great danger of extension to the peritoneum, or of the 
formation of a tubal or other form of pelvic abscess that 
will imperil the life of the woman. 

As a general rule, it may be said that, unless there are 
well-marked symptoms of extensive pelvic peritonitis, 
or unless a distinct tumor can be felt in the pelvis, ope- 
ration is not indicated. As resolution undoubtedly takes 
place even after severe acute attacks of salpingitis, it is 
right to treat the woman with this end in view rather 
than to resort to an immediate mutilating operation. 

If, under the expectant plan of treatment, the patient 
does not improve; if the area of pelvic tenderness in- 
creases; if the local tympany (which may at first be 
present only on one or both sides of the pelvis, and 
which indicates merely local peritoneal irritation or in- 
flammation) extends upward; if the temperature and 
pulse-rate increase; if constipation appears; if, in fact, 
indications of extension of the peritonitis are present, — 
celiotomy should be immediately performed. The dis- 
eased tube or tubes should be removed, and, if necessary, 
the abdomen should be drained. 

Fatal peritonitis sometimes results within three or four 
days after the onset of acute salpingitis. As soon, there- 
fore, as the physician realizes the imminence of this 
complication in any case, he should not delay in remov- 
ing the source of infection. 

The other acute termination of salpingitis, the forma- 
tion of an abscess in the pelvis, likewise demands opera- 
tive interference. This condition is readily recognized. 
The woman has one or more chills. The temperature 



298 A TEXT-BOOK OF DISEASES OF WOMEN. 

becomes more elevated and the pulse more rapid. The 
pelvic tenderness and pain may become more distinctly 
localized to one or both ovarian regions. Defecation and 
urination increase the pain. Bimanual examination re- 
veals an exceedingly tender mass, either indurated or 
perhaps soft and fluctuating, lying to either side of, or 
behind the uterus. The character, upon palpation, of 
the mass depends upon the nature and extent of the peri- 
toneal adhesions that surround it. The diagnosis of a 
pelvic abscess resulting from acute salpingitis is usually 
easy. 

There is some difference of opinion among operators in 
regard to the best treatment for this condition. Some 
advise evacuation of the abscess by way of the vagina; 
others advise celiotomy, with removal of the abscess and 
the Fallopian tube that caused it, followed, if necessary, 
by abdominal or vaginal drainage. I prefer the latter 
method of treatment, for reasons that will appear under 
the consideration of the technique of operation. 

Treatment of Chronic Salpingitis. — Cases of simple 
chronic catarrhal salpingitis undoubtedly recover after 
the cure of the endometrial disease of which the salpin- 
gitis forms a part. The tube may be restored perfectly 
to its normal condition; or there may remain an atrophic 
condition of the mucous membrane; or the fimbriae may 
be left somewhat distorted, crumpled, or slightly drawn 
within the tube; or there may be a few fine peritoneal 
adhesions, like cobwebs, between the distal end of the 
tube, the broad ligament, and the ovary. Such slight 
lesions may cause no trouble beyond interfering a little 
with the fecundity of the woman. 

When, however, the adhesions are more extensive, 
treatment for their relief may be demanded, even though 
all inflammatory action has disappeared from the body of 
the uterus and the tubes. Treatment in such cases is 
demanded, not to cure the salpingitis or on account of 
any danger that threatens the woman's life, but to relieve 
the pain caused by the results of the inflammation. 



DISEASES OF THE FALLOPIAN TUBES. 299 

It may be necessary to perform celiotomy in order to 
free or break up adhesions that bind down the ovary in 
an abnormal position, or to liberate an adherent intestine, 
or to replace a uterus that has been displaced by the trac- 
tion of adhesions. 

The degree of suffering experienced by the woman is 
the guide in advising such operative interference. 

Pelvic massage has been used for the relief of pelvic 
adhesions of this kind, the uterus, tubes, and ovaries being 
manipulated between the fingers in the vagina and a 
hand upon the abdomen. The results of this treatment 
have not been encouraging. 

In discussing the treatment of chronic salpingitis the 
cases may be divided into two classes: those in which 
palliative treatment may be followed, and those in which 
operation is demanded. 

There are a great number of cases of chronic salpin- 
gitis in which there is no gross disease of the tubes, and 
in which operation upon the tubes is not immediately 
indicated. It is proper in such cases to try milder pallia- 
tive treatment first. 

Salpingitis is always preceded, and usually accom- 
panied, by inflammation of the endometrium, and in 
every chronic case attention should first be directed to 
the cure of the endometritis. 

If there is no tubal and ovarian displacement— that 
is, if the ovary is not prolapsed; if the uterus has not 
been retroverted; if there are no extensive tubal adhe- 
sions; and if there is no gross disease of the tube, such 
as pyosalpinx, hydrosalpinx., hematosalpinx, a thorough 
curetting of the uterus, or, if necessary, a trachelorrhaphy 
or an amputation of the cervix, will often relieve the 
woman of her suffering, and it may not be necessary to 
operate for the damaged tubes. 

In all such cases, however, the operator must be very 
careful to exclude active or purulent tubal disease. If he 
overlooks a pyosalpinx, the curettage or the trachelor- 
rhaphy may be followed by an active peritoneal inflam- 
mation that will destroy the woman. 



300 A TEXT-BOOK OF DISEASES OF WOMEN. 

If there is ovarian or uterine displacement, we cannot 
expect relief until these conditions have been treated, and 
such treatment usually requires celiotomy. 

The pain and dysmenorrhea of chronic tubal disease 
may be relieved by rest in the recumbent position during 
the menstrual period; by the administration of saline 
laxatives (the pain is always increased by constipation); 
by vaginal douches of large quantities of hot water (one 
gallon at no° F.) administered two or three times a day 
in the recumbent posture; and by applications of Church- 
ill's tincture of iodine to the vaginal vault, and the use 
of the glycerin tampon. The directions for this treat- 
ment have been given under the preparatory treatment 
of laceration of the cervix. 

Such treatment is only palliative: it relieves the pain, 
but it will not cure well-established chronic salpingitis. 

In many cases the woman experiences little, if any, 
relief from this treatment. In other cases, though the 
pain may be very much relieved while she is taking treat- 
ment, yet it returns as soon as the treatment is stopped, 
and she becomes unwilling to lead the life of an invalid 
under constant medical care, with but little prospect of 
relief until the menopause is reached. It is then neces- 
sary to consider operation. 

The second class of cases referred to — those in which 
immediate operation is demanded, and in which it is 
dangerous to delay and useless to try the palliative treat- 
ment — includes a great variety. Such cases are — the 
gross forms of tubal disease, hydrosalpinx, hematosal- 
pinx, and pyosalpinx; salpingitis with prolapsed and ad- 
herent tube and ovary; salpingitis with retrodisplace- 
ment of the uterus; all the milder forms of salpingitis 
which have resisted palliative treatment. 

The operative treatment of salpingitis usually demands 
celiotomy. Some operators, however, prefer to reach the 
uterine appendages by way of the vagina. 

The details of the operative technique of salpingo- 
oophorectomy will be given in a subsequent chapter. As 



DISEASES OF THE FALLOPIAN TUBES. 3 QI 

a rule, the operation of celiotomy for salpingitis should 
always be immediately preceded by thorough curetting 
of the uterus and, if necessary, by trachelorrhaphy or 
an amputation of the cervix. 

After the abdomen has been opened the operation con- 
sists in freeing adhesions, rendering patulous the abdom- 
inal ostium of the tube, replacing the uterus, and, if 
necessary, removing the tube and ovary on one or on 
both sides. 

Removal of the tubes and ovaries — salpingo-oophorec- 
tomy — is usually necessary. In pyosalpinx this operation 
should always be performed. If the woman is young and 
is very anxious to have children, every attempt should be 
made to save, at any rate, one tube and ovary. Remark- 
able cases of conception have occurred after conservative 
operations upon badly diseased tubes. 

The adhesions about the abdominal ostium may be 
broken and the imprisoned fimbriae freed; or if the os- 
tium is firmly closed, an incision may be made in the 
wall of the tube, the peritoneum stitched to the mucous 
coat, and a new ostium produced. In one case concep- 
tion followed such an operation in which the ovary was 
sutured in the artificial opening made in the tube. Con- 
ception has occurred after both tubes had been amputated 
at the uterine cornua. 

In all such conservative operations, however, the 
woman should be told of the probability of failure and 
the probable necessity for a subsequent radical operation. 
The successful cases show the possibilities of surgery, 
but, unfortunately, they are exceptional. Sterility usu- 
ally continues, the pain is usually unrelieved, and a sec- 
ond radical operation becomes necessary. 

Such conservative operations upon badly diseased 
tubes should be performed, therefore, only when the 
woman is young and anxious for children. Whenever 
the abdominal ostium is closed and the ovary is adherent, 
it is safest to perform a complete salpingo-oophorectomy. 
This is always indicated when the woman is near the 



2,02, A TEXT-BOOK OF DISEASES OF WOMEN. 

menopause or when immediate certain relief is demanded 
from prolonged suffering. 

In some cases the question arises as to whether both 
tubes should be removed when only one is grossly dis- 
eased. In the early stages of chronic pyosalpinx it often 
happens that but one tube is found diseased, while the 
other is apparently perfectly healthy or is only slightly 
adherent. Experience has shown that in a great many 
cases of tubal disease in which only one tube was re- 
moved, the second tube has become similarly affected, 
often within a short time, and a second operation has 
been required. This disaster is not likely to occur if the 
endometrial disease is eradicated by thorough curetting^ 
at the time of the first operation. But in some forms of 
salpingitis, as the gonorrheal, the infection is so deeply 
seated in the distal ends of the utricular glands that the 
most vigorous curetting fails to remove it, and the sec- 
ond tube will become infected from the original focus in 
the uterus. 

So common is such occurrence that many women, 
profiting by the experience of their friends, request the 
operator to remove both tubes, even though he finds but 
one diseased. The advice already given in regard to con- 
servative operation applies here also. It is safest in all 
forms of pyosalpinx to remove both appendages. In the 
less serious forms of salpingitis — hydrosalpinx and ad- 
herent tubes without cystic distention — there is less dan- 
ger of recurrence, and the unilateral operation may be 
more safely performed. The importance of thorough 
treatment of the endometritis at the same time is empha- 
sized by these considerations. 

In many cases in which double salpingo-oophorectomy 
is performed it is often advisable to remove the uterus at 
the same time. The uterus may be amputated at any 
convenient point of the cervix, or it may be completely 
removed at the vaginal junction. This operation ensures 
more certain and speedy relief from suffering, and is 
attended by but little, if any, greater mortality than the. 






DISEASES OF THE FALLOPIAN TUBES. 303 

simple salpingo-oophorectomy. The uterus without the 
tubes and ovaries is a useless structure. The operation 
is advisable if the uterus is retroverted and adherent, 
when the uterus is large and subinvoluted, when the dis- 
ease of the endometrium is severe and is likely to persist 
— in any case, in fact, in which the physician fears that 
the uterus may be a subsequent source of trouble. 

SUPPURATION OF THE PELVIC CELLULAR TISSUE. 

Pus in the female pelvis, to which condition the vague 
term of pelvic abscess has been applied, is usually the 
result of salpingitis producing a pyosalpinx, of ovarian 
abscess, or of suppuration of an ovarian cyst, very often 
a dermoid. The disease may also occur from infection 
of a broad-ligament hematoma or from a pelvic hemato- 
cele caused by a ruptured tubal pregnancy. 

Following these conditions the cellular tissue of the 
pelvis may become affected, so that the purulent accu- 
mulation may make its way between the layers of the 
broad ligament or in some other part of the pelvis. 

Before the days of modern abdominal surgery these 
accumulations of pus were evacuated through the vagina, 
the rectum, or the abdominal wall, according to the direc- 
tion in which the abscess seemed to point or in which it 
seemed to be most accessible. The sinuses thus formed 
often persisted for years or during the remaining life of 
the woman. There were many theories in regard to the 
origin of the suppuration, it being impossible to deter- 
mine its true nature without opening the abdomen. 
Now we know that the great majority of such pelvic 
abscesses originated in septic infection of the Fallopian 
tubes, and that infection of the pelvic cellular tissue 
was secondary. 

There are, however, rare cases in which the suppura- 
tion occurs primarily in the cellular tissue of the pelvis, 
without any involvement whatever of the tubes or 
ovaries. Such an accumulation of pus is usually found 
in the cellular tissue of the broad ligaments: it some- 



304 A TEXT-BOOK OF DISEASES OF WOMEN. 

times occurs in the utero- vesical tissue, and rarely in the 
tissue back of the cervical neck. 

The cause of such suppuration is usually infection, by 
way of the lymphatics, from the uterus, or by the pas- 
sage of septic organisms directly through the uterine wall. 
The condition is most frequently the result of puerperal 
sepsis. I have on one occasion seen it occur in connec- 
tion with extensive venereal ulceration of the external 
genitals. It seems probable that a pelvic lymphatic 
gland, becoming infected, may break down and sup- 
purate, forming the starting-point of the abscess. 

The symptoms of this form of pelvic abscess are those 
characteristic of any other kind of suppuration in the 
pelvis. 

The purulent accumulation may be detected by bi- 
manual examination. It usually bulges into the vagina 
at the lateral fornices or before or behind the cervix. 
The abscess-mass is in close relationship with the uterus. 
In this respect it differs from a simple tubal or an ovarian 
abscess, in which cases a distinct separation of the tubal 
or ovarian tumor from the uterus may be determined, at 
any rate, before the pelvic cellular tissue has become in- 
volved. 

If the abscess bulge in the anterior vaginal fornix, it 
is very probably of neither tubal nor ovarian origin, as 
tubal and ovarian abscesses lie to the side of, or behind, 
the uterus. 

The sense of fluctuation is often difficult or impossible 
to determine. The infiltration of the surrounding struc- 
tures gives to the mass a dense hard feeling that obscures 
fluctuation. To the experienced finger, however, this 
indurated condition of the tissues is characteristic of 
pelvic suppuration, as is the sense of fluctuation else- 
where. 

The treatment of pelvic suppuration of this nature is 
evacuation by way of the vagina. The incision should 
be made into the most prominent part of the mass. 
When made into the lateral fornices, the operator should 



DISEASES OF THE FALLOPIAN TUBES. 305 

remember the position of the ureters and the uterine 
arteries. The ureters lie a little over half an inch from 
the cervix. In every case it is safest to make the incision 
close to the cervix and to work carefully into the abscess- 
cavity. The pus should be evacuated, and a double drain- 
age-tube should be introduced for subsequent washing. 

In most cases, however, the physician cannot deter- 
mine with any certainty that the abscess is simply con- 
fined to the pelvic cellular tissue and did not originate in 
the Fallopian tube. If there is any doubt of this kind, 
celiotomy should be performed and the true nature of the 
condition determined. If a pyosalpinx or an ovarian 
abscess is present, as is usually the case, the condition 
may be dealt with as has already been advised. If the ute- 
rine adnexa are healthy, the abdomen may be closed and 
a subsequent vaginal incision may be made. 

Indiscriminate evacuation of collections of pus in the 
pelvis by way of the vagina has resulted in a great deal 
of harm. The abscess, being usually of tubal origin, 
often persists indefinitely. Intestine, ureters, bladder, 
and blood-vessels have often been injured; and when sub- 
sequent celiotomy is performed the operation is attended 
with great danger from the presence of the fistulous 
opening. 



29 



CHAPTER XXV. 
DISEASES OF THE FALLOPIAN TUBES (Continued). 

TUBERCULOSIS. 

Tuberculosis attacks the Fallopian tubes much more 
frequently than any other part of the genital apparatus. 
The disease may be associated with tuberculosis of the 
peritoneum or with tuberculosis of the ovaries and the 
uterus. As has already been said, tuberculosis of the 
uterus often originates in the tubes and extends thence to 
the endometrium. 

The tubercular Fallopian tube varies much in appear- 
ance according to the nature and stage of the disease. 
The strictly tubercular lesions may be masked by those 
of ordinary inflammation. There may be peritoneal ad- 
hesions, often very dense and widespread, between the 
tube and adjacent organs, and the ostium abdominale 
may be closed, as in non-tubercular salpingitis. 

In some cases these simple inflammatory adhesions 
probably existed before the tubercular infection took 
place, the tuberculosis occurring in an old diseased tube. 
In other cases it is probable that the inflammatory ad- 
hesions and products occurred as a result of the tuber- 
culosis, which attacked a tube previously healthy. In 
the latter case such adhesions may be viewed as a conser- 
vative process. 

The tubercular tube is often very much enlarged from 
infiltration of its walls and dilatation of its lumen. It 
may be filled with typical caseous material, and when 
this is removed the mucous membrane will be found the 
seat of deep, jagged, ulcerated areas. 

If the abdominal ostium is not entirely closed, the 
cheesy material may project into the abdominal cavity. 

306 



DISEASES OF THE FALLOPIAN TUBES. 307 

If the disease has extended to the peritoneal coat, the 
covering of the tube will be found studded with typical 
tubercles (Fig. 153)0 Such tuberculosis of the perito- 
neum may be confined to that covering the tube, or it 
may extend to the uterus and throughout the abdominal 
cavity. 

In peritoneal tuberculosis that has originated in the 
tube the lesions are found to be most widespread in the 
pelvic peritoneum. 

In some cases the ostium becomes closed, and the tubes 




Fig. 152. — Tuberculosis of the Fallopian tubes. The disease has extended to 
the peritoneum, which is covered with tubercles. 

are found distended with pus, forming tubercular pyo- 
salpinx. Such tubes sometimes attain enormous size, 
containing a quart or more of purulent material. 

In less extreme cases than those just described the tu- 
bercular area may be limited to a portion of the tube, 
and gives rise to one or more nodular enlargements (Fig. 
153). In other cases there is no gross change in the shape 
or size of the tube, and only a few miliary tubercles are 
found scattered throughout the mucous membrane. 

In a very large number of the cases of tuberculosis of 
the Fallopian tubes, the lesions resemble in all respects 
those of ordinary salpingitis, and are not in any way rec- 
ognizable by the naked eye as characteristic of tuber- 






308 A TEXT-BOOK OF DISEASES OF WOMEN. 

culosis. There are no cheesy contents; there are no tu- 
bercles upon the peritoneum; the mucous membrane 
shows no macroscopical changes that would lead to the 
suspicion of tuberculosis. In these cases the tubes are 
usually closed at the abdominal ostium; there may or 
may not be cystic distention; and the adhesions, which 
are usually very firm, distort the shape of the tube and 
bind it to the posterior aspect of the broad ligament, 
the uterus, or other pelvic structure. Until recent years 




Fig. 153. — Tuberculosis of the Fallopian tubes: A, tubercular nodules. 



such cases were supposed to be simple cases of salpin- 
gitis. Careful microscopic examination, however, has 
shown that this forms one variety of tubal tuberculosis, 
and that a certain proportion of such cases of salpingitis 
are tubercular. The term "unsuspected tuberculosis" 
has been applied by Williams to such cases. 

Cases of tuberculosis of the Fallopian tubes may be 
divided into three classes: Miliary tuberculosis; chronic 
diffuse tuberculosis (cheesy tubes); and chronic fibroid 
tuberculosis. 

Miliary tuberculosis of the tubes may be a part of a 
general miliary tuberculosis, or it may occur primarily 
in the tube. Microscopic examination shows giant epi- 
thelioid cell-tubercles scattered throughout the mucous 
membrane. 



DISEASES OF THE FALLOPIAN TUBES. 309 

Miliary tuberculosis is the first stage of tuberculosis of 
the tubes. The process may progress no farther, or it 
may become converted into one of the other varieties. 

In chronic diffuse tuberculosis the mucous membrane is 
infiltrated with epithelioid cells, miliary tubercles, and 
areas of caseation. The tube may be filled with cheesy 
material or with pus, and in time the mucous membrane 
becomes completely destroyed. In this form of tubercu- 
losis the gross appearances are usually characteristic, and 
are those which have already been described. 

In chronic fibroid tuberculosis there is a great increase 
of connective tissue between the tubercles. The lumen 
of the tube is distorted, and a few miliary tubercles are 
found scattered through the mucous membrane. This 
form of the disease is very slow and chronic, and repre- 
sents a usual method of spontaneous cure. 

Since the discovery of so-called unsuspected tuber- 
culosis of the Fallopian tubes the disease has been found 
to be much more frequent than was formerly supposed. 

Williams found tuberculosis of the tubes in one out of 
every twelve operations for the removal of tubes and 
ovaries that were the seat of past or present inflammatory 
disease. 

Dr. Beyea and I have found tuberculosis of the tubes 
present in 18 per cent of the cases that were subjected to 
the operation of salpingo-oophorectomy for inflammatory 
disease of the tubes. 

It may be said, therefore, that tuberculosis is present 
in from 8 to 18 per cent, of all cases of inflammatory 
disease of the uterine appendages. It is impossible, 
however, to say whether or not tuberculosis is the cause 
of the disease in all cases, or whether tuberculosis has 
been grafted upon a previous non-tubercular affection. 
Other organisms, along with the tubercle bacillus, are 
frequently found in the Fallopian tube. 

Tuberculosis of the Fallopian tubes may be primary 
or secondary. 

In primary tuberculosis the tubes are the primary seat 



3IO A TEXT-BOOK OF DISEASES OF WOMEN. 

of the disease, being affected before other structures of 
the body. 

In secondary tuberculosis the tubes are affected from a 
tubercular focus in some other part of the body. 

Tuberculosis of the tubes is usually secondary. 

Infection takes place in a variety of ways. Infection 
through the blood is the most usual way. 

Infection may take place from a tubercular ulcer of the 
intestine or bladder becoming adherent to the tube. The 
tube may become involved by extension of tuberculosis 
of the peritoneum to it. In many cases the reverse order 
happens: the tube is first involved by the tuberculosis, 
and the disease extends thence to the peritoneum. In 
other cases it is the peritoneum that is primarily affected. 
It seems probable that tubercle bacilli, having gained 
entrance to the peritoneum from a tuberculous mesen- 
teric gland or from an intestinal ulceration, fall to the 
pelvis .and are drawn into the Fallopian tubes, there 
producing tuberculous lesions without first affecting the 
peritoneum. 

It seems probable that in a good many cases of tuber- 
culosis of the tubes the infection takes place from with- 
out by way of the genital tract. Dirty instruments, 
syringes, or the examining finger may cause it in this 
way. Infection may also occur from clothing or bed- 
sheets soiled by sputum or other tubercular discharge. 
Coitus with men affected with geni to-urinary tuberculosis 
or any other form of tuberculosis may be an occasional 
cause. It has been shown that tubercle bacilli may be 
present in the testes and prostate glands of consumptives 
without any evidence of genito-urinary tuberculosis being 
present. 

Tubal tuberculosis may occur by way of the genital 
tract from infection from the discharges from some other 
tubercular focus in the woman, as in the lungs, bladder, 
or intestinal tract. 

The symptoms of tuberculosis of the Fallopian tubes 
are not at all characteristic. Most cases of tubal tuber- 



DISEASES OF THE FALLOPIAN TUBES. 311 

culosis have been discovered at the autopsy or have been 
unexpectedly found at operation. 

The symptoms resemble those of non-tubercular sal- 
pingitis. There is the same ovarian pain and dysmenor- 
rhea. Bimanual examination reveals the enlarged or 
nodular and distorted condition of the tube. The adhe- 
sions are often very firm and dense, and the tubal tumor 
is often of stony hardness. 

The diagnosis of uncomplicated tubal tuberculosis is 
difficult, and in many cases impossible. If the peritoneal 
covering of the tube is involved, the small tubercles may 
sometimes be felt by vaginal or rectal palpation. Or, if 
the condition has extended to the posterior aspect of the 
uterus, the tubercles may be felt here, by dragging the 
cervix down with a tenaculum and palpating the poste- 
rior uterine surface with a finger in the vagina or the 
rectum. The association of salpingitis with pulmonary 
tuberculosis would lead the physician to suspect that the 
salpingitis might be tubercular. If the woman has tuber- 
culosis of the peritoneum, and the tubes are found en- 
larged, it is most probable that they are tubercular. A 
knowledge of a genito-urinary lesion of tubercular nature 
in the husband should lead us to fear tubal tuberculosis 
in the wife. 

Prognosis. — Tubal tuberculosis is a dangerous disease. 
There are several methods of termination. It very often 
leads to tuberculosis of the peritoneum. For this reason 
peritoneal tuberculosis is more common in women than 
in men. 

A tubercular abscess may be formed in the pelvis, and 
the woman may die as the result of prolonged discharge 
and suppuration, as in the case of non-tubercular pyo- 
salpinx. General tubercular infection may arise from 
the tubercular focus in the tubes. 

Tuberculosis of the tubes may, and probably often 
does, undergo spontaneous cure. The fibroid changes 
that have been described lead to this end. In some cases 
calcification occurs, as in tuberculosis elsewhere, and the 



312 A TEXT-BOOK OF DISEASES OF WOMEN. 

disease is cured in this way. Fig. 154 represents an old 
tubercular pyosalpinx that was filled with calcified plates. 

Even though these conservative changes take place and 
all danger from the tuberculosis has disappeared, the 
woman will continue to sutler pain and dysmenorrhea 
from the tubal and ovarian adhesions. 

Treatment.— The treatment of tubal tuberculosis is 
celiotomy, with removal of the tubes and ovaries. If 
the uterus is involved, it should also be removed. Re- 
moval of the tubes, however, is the important feature of 
the operation. I have seen perfect and permanent re- 
covery occur after removing the tubes, even though the 




Fig. 154. — A tubercular pyosalpinx. To the left are three calcified plates that 
were found in the tube. 

disease had extended into the uterine cornua. As the dis- 
ease very rarely extends below the internal os, the uterus 
may be amputated at any convenient point of the cervix. 
Tuberculosis of the peritoneum is an indication for, 
rather than a contraindication to, the operation. The 
most extensive cases of peritoneal tuberculosis have been 
cured by opening and draining the abdomen. If the 
tubes are rendered inaccessible from the involvement of 
surrounding structures, the operator must content him- 
self with opening and draining the abdomen. 



DISEASES OF THE FALLOPIAN TUBES. 313 

Adenoma of the Fallopian tube is a rare disease; but 
a few cases have been described in medical records. The 
presence of primary adenoma in the Fallopian tube is 
strong proof of the glandular character of the mucous 
membrane — an anatomical point which, as has already 
been said, has been denied by some writers. In adenoma 
the tube becomes distended with the typical adenomatous 
mass, which may protrude from the abdominal ostium. 

In some of the reported cases there has been found a 
considerable quantity of free fluid in the peritoneum, 
though the peritoneum itself was not diseased. It seems 
probable that this secretion originated in the tube and 
escaped at the ostium. 

Myoma. — Notwithstanding the frequency of myoma- 
tous tumors of the uterus, the condition is exceedingly 
rare in the Fallopian tubes. The tumors originate in the 
muscular coat, and are usually so small as to create no 
disturbance. 

Cancer. — Primary cancer of the Fallopian tubes is an 
extremely rare disease. A very few isolated cases have 
been reported. 

Cancer of the tubes secondary to cancer of the body 
of the uterus occurs more frequently. 

Sarcoma of the tube is a very rare disease. 

Actinomycosis of the Fallopian tubes has been de- 
scribed. 

Syphilitic gummata occasionally attack the Fallo- 
pian tube in women who are the victims of constitu- 
tional syphilis. 

The diagnosis of these unusual lesions of the Fallopian 
tubes is impossible with our present knowledge. The 
conditions have usually been found post-mortem or have 
been unexpectedly discovered at operation. The subjec- 
tive symptoms throw no light upon the subject of differ- 
ential diagnosis. Examination reveals merely a tubal 
tumor. 

As the rule is to operate in all cases of tubal tumor, 
the proper treatment will probably be applied, notwith- 
standing the uncertainty or mistake of diagnosis. 



CHAPTER XXVI. 
TUBAL PREGNANCY. 

Tubal pregnancy occurs when a fecundated ovum is 
developed in the Fallopian tube. 

Fecundation may take place in the Fallopian tube, be- 
cause spermatozoa may pass through the uterus and the 
tube into the pelvic cavity; but unless something occurs 
to arrest the passage of the fertilized ovum into the 
uterus, a normal uterine pregnancy will result. It is said 
by Webster that predisposition to tubal pregnancy is due 
to a "developmental fault, whereby there is reversion, 
either of structure or reaction tendency, in the tubal 
mucosa to an earlier type in mammalian evolution." 

In other words, decidual changes, following the fertil- 
ization of the ovum, may in some women occur in the 
mucous membrane of the Fallopian tubes as well as in 
that of the uterus. If this condition is present in any 
case, and at the same time something occurs to impede 
the passage of the ovum into the uterus, a tubal preg- 
nancy may take place. 

Interference with the passage of the ovum along the 
tube has been attributed to a variety of causes. Chronic 
salpingitis is a frequent cause. It destroys the cilia of 
the epithelial cells of the tubal mucosa. It produces 
thickening of the tubal walls, and causes peritoneal 
adhesions that impede the normal peristaltic action of 
the tube. 

Obstruction to the passage of the ovum may also be 
caused by polypi or tumors of the tube; by tumors ex- 
ternal to the tube pressing upon it; by displacement and 
hernia of the tube; by diverticula of the tube; or by ab- 
normal foldings of the tubal wall. Tubal pregnancy has 

314 



TUBAL PREGNANCY. 



3*5 



occurred in tubes in which no lesions whatever could be 
discovered by the most careful examination. 

It seems probable that practically all pregnancies that 
occur outside of the uterus originate in the Fallopian tube. 

Pregnancy may occur in any part of the tube from the 
abdominal ostium to the uterus. 

Tubal pregnancy is said to be infundibular when ges- 
tation begins in the infundibulum or in an accessory tube- 






-GHOMO/MtU VILLI 




^ 



Fig. 155. — Tubal pregnancy, removed before rupture. The opening that has 
been cut in the tube shows the chorionic villi. 



ending. This variety has also been called tubo-ovarian, 
because in time the gestation-sac may become adherent 
to the ovary and be bounded by both tube and ovary. 

The pregnancy is said to be ampullar when gestation be- 
gins in the ampulla of the tube. This is the most usual 
seat of tubal pregnancy. It is called interstitial when 
gestation begins in the interstitial portion, or that part of 
the tube in immediate relationship with the uterus. 

Changes in the Fallopian Tnbe. — During the early 
stages of tubal pregnancy — the first two or three months 



316 A TEXT-BOOK OF DISEASES OF WOMEN. 

— it seems probable that a certain amount of hypertrophy 
and hyperplasia of the muscular wall of the tube takes 
place. The general form of the tube is spindle-shaped 
(Fig. 155). There is a marked increase in the vascularity 
of the tube, most pronounced in the neighborhood of the 
ovum. The whole tube becomes turgid and swollen. 
The peritoneal margin or ring surrounding the ostium 
abdominale becomes prominent, and gradually, as has 
already been described under Salpingitis, projects beyond 
the fimbriae, contracts, and ultimately hermetically closes 
the ostium. 

Inflammation of the peritoneal covering of the tube 
may be present. Such inflammation may have preceded 
the tubal pregnancy or may have occurred as the result 
of the pregnancy. It produces various tubal adhesions 
and distortions, and may still more firmly close the ab- 
dominal ostium. The changes that take place in the 
mucous membrane of the tube and in the developing 
ovum are similar to those that occur in the uterus in a 
normal pregnancy. 

A variety of terminations occur in tubal pregnancy: 

I. In very exceptional cases the pregnancy may con- 
tinue until full term, without rupture of the tube taking 
place. 

II. The tube may rupture. This is by far the most 
usual occurrence. The rupture may take place into the 
broad ligament, into the peritoneal cavity, or, in the case 
of interstitial tubal pregnancy, into the uterus. 

III. Tubal abortion may occur, the ovum being dis- 
charged through the abdominal ostium into the perito- 
neal cavity. 

IV. The ovum may be destroyed in the tube, gestation 
being stopped before rupture takes place. 

Rupture of the tube is the rule in tubal pregnancy. 
The time of rupture depends upon the position of the 
ovum in the tube. It occurs somewhat later in the inter- 
stitial variety than when the ovum is situated in the free 
portion of the tube. Rupture in interstitial pregnancy 



TUBAL PREGNANCY. 317 

commonly occurs before the fifth month. In the other 
forms of tubal pregnancy it occurs most usually before 
the end of the third month. In the latter class of cases 
the greatest number of ruptures occur during the second 
month. 

Rupture is caused by the gradual thinning of the tube 
from distention. Rupture may take place suddenly, a 
large hole, through which the ovum escapes, being pro- 
duced; or the rupture and discharge of the ovum may 
take place gradually without causing any acute symp- 
toms. 

When the rupture takes place between the layers of 
the broad ligament, the hemorrhage is usually not very 
profuse, as it is controlled by pressure of the structures 
that surround the blood. A broad-ligament hematoma 
is formed. The ovum may be destroyed as a result of 
the rupture, and no further lesions due to the develop- 
ment of gestation will arise. The hematoma, with the 
ovum, may in time be absorbed; or suppuration may oc- 
cur, with the production of a pelvic abscess; or mummi- 
fication, adipoceration, or lithopedion formation may take 
place in the fetus. 

If the ovum is not destroyed by the rupture, it may con- 
tinue to develop in the cavity formed by the tube and the 
broad ligament. The placenta may remain attached to 
the inner surface of the tube, or it may contract adven- 
titious attachments to any of the surrounding structures — 
the surface of the uterus and the pelvic floor. The cavity 
occupied by the ovum may continue to enlarge, by the 
pushing aside of pelvic and abdominal organs, until full 
term is reached and spurious labor comes on. 

In some cases a secondary rupture of the gestation-sac 
occurs, and the fetus is discharged into the peritoneal 
cavity. 

When rupture of the tube into the peritoneal cavity 
occurs, the danger of fatal hemorrhage is very great. 
The majority of women die within forty-eight hours after 
this accident, unless relieved by immediate laparotomy. 



318 A TEXT-BOOK OF DISEASES OF WOMEN. 

There is no surrounding pressure to control the hemor- 
rhage, as in the case of rupture into the broad ligament. 
Sometimes the escaping ovum plugs the rent in the tube, 
and bleeding is checked in this way. 

If the woman survive the effects of hemorrhage, she 
may die from peritonitis or from suppuration of the he- 
matocele in the peritoneal cavity. 

In exceptional cases, if the pregnancy be early, the 
blood and the ovum may be absorbed by the peritoneum, 
and spontaneous recovery occurs. 

If the woman is not destroyed by the first effects of 
the rupture, the fetus, surrounded by its membranes, 
may escape into the peritoneal cavity, while the placenta 
may remain attached to the tube and gestation may con- 
tinue. It is very doubtful whether the fetus will continue 
to live if it escapes into the peritoneum free of the mem- 
branes. There is no evidence that an early ovum may 
escape into the cavity of the abdomen and develop on the 
peritoneum. 

If the fetus does not survive, it may be absorbed by the 
peritoneum or mummification may occur. 

Tubal abortion means the separation of the ovum from 
the tube-wall, and its partial or complete discharge 
through the ostium abdominale into the peritoneal cav- 
ity. The accident is accompanied by hemorrhage into 
the tube and thence into the peritoneal cavity. 

Tubal abortion is most likely to occur during the early 
weeks of pregnancy (the first and the second months), 
before the abdominal ostium has become closed. 

It is probable that tubal abortion is much more fre- 
quent than is generally supposed. According to Sutton, 
tubal abortion was probably the cause of the peritoneal 
hematocele in many cases in which the bleeding was 
attributed to other origin, as reflux of menstrual blood 
from the uterus and simple hemorrhage from the tube. 

In tubal abortion the loss of blood into the peritoneum 
may be so great that the woman is destroyed. In other 
cases death results from peritonitis and suppuration of 




Fig. 156. — Extra-uterine pregnancy; tubal abortion. The bleeding is checked by a large 
coagulum distending and thinning out the tube ; the fimbriated opening is greatly distended, 
jut the greater diameter of the clot in the ampulla prevents its escape. Wall of tube aver- 
aging 1 millimeter in thickness. Operation. Recovery, July 7, 1896. Natural size. (Kelly. 
Copyright, 1898, by D. Appleton & Co.) 





lftfffr£_ 


1 


^?*^^^r^H^BH 


x *fev?§^ 


. ' '■ 


0:/""' \"* \ *-**) 1 


' : '"-^-- v : ' i-' ■?:' \) 






f ) 


'^.;,wf '■<;■' : "'' 




^Wf' 



Fig. 157. — Coagulum turned out, showing a oast of the tube extending up into the isthmus. 
On its surface lies the fetus. Natural size. (Kelly. Copyright. 1898, by D. Appleton & Co.) 

RIO 



3 20 A TEXT-BOOK OF DISEASES OF WOMEN. 

the hematocele. And, finally, in a good many cases the 
"blood and ovum may be absorbed, and recovery takes 
place. Sometimes, at operation, the ovum is found in 
the peritoneal cavity without any blood. The blood had 
either been small in amount and quickly absorbed, or 
there had been no escape of blood into the peritoneum. 
Blood-clot is usually found in the Fallopian tube after 
tubal abortion. The ostium may become closed and a 
hematosalpinx may result. 

When the ovum is destroyed in the tube before rupture 
takes place, the fetus and the blood may be absorbed; or 
mummification, adipoceration, or lithopedion-formation 
may result; or suppuration may occur, with the forma- 
tion of a pyosalpinx; or, if death of the fetus happens in 
the early weeks, the tube may be found closed at the 
ostium abdominale, and filled with blood in which no 
fetus may be detected. Such cases have been repeatedly 
described as hematosalpinx, the real origin of the condi- 
tion in pregnancy not being known. The fetus had been 
absorbed or broken up and scattered through the blood- 
mass. Careful microscopic examination of the tube re- 
veals the true condition — a destroyed tubal pregnancy 
with hemorrhage into the tube. As has already been 
said, hematosalpinx not caused by tubal pregnancy is 
very rare. 

Coincidently with the development of the tubal preg- 
nancy there occur enlargement of the body of the uterus 
and decidual transformation of the endometrium. The 
decidual membrane separates, entire or in fragments, and 
is discharged from the uterus, after the death of the 
embryo or during its development, from the eighth to 
the tenth week. The decidua again forms only when 
gestation continues undisturbed. 

The enlargement of the uterus varies a great deal ac- 
cording to the position of the tubal pregnancy and the 
course of its development. The interstitial variety is ac- 
companied by the greatest uterine enlargement. When 



TUBAL PREGNANCY. 321 

the tubal gestation has reached full time the uterus may 
measure from 4. to y}4 inches in length. 

The increased size of the uterus is most marked in the 
long diameter. The change of shape does not resemble 
that which occurs in normal pregnancy. 

The uterus also becomes softer in tubal pregnancy, and 
the cervix softens somewhat, though not so much as in a 
uterine pregnancy. 

If the woman and the fetus survive the many dangers 
that accompany the progress of tubal gestation, the 
development of the fetus will go on to full term, and 
then the phenomenon of spurious labor will come on. 

In spurious labor there are a series of periodical pains 
that resemble those of normal labor. The pains may last 
from a few hours to several days. They may cease, and 
reappear after varying intervals. 

Hemorrhage usually takes place from the uterus. After 
the spurious labor the uterine discharge may be of the 
same character as that seen after normal labor. 

It is probable that the fetus always dies after spurious 
labor. The liquor amnii is absorbed, the gestation-sac 
shrinks, and changes take place in the fetus similar to 
those already referred to. It may become mummified or 
converted into adipocere or a lithopedion. In this condi- 
tion it may remain in the abdomen for many years. A 
mummified fetus that had been carried for fifty years has 
been removed post-mortem from a woman aged eighty- 
two. 

Rarely, after spurious labor the gestation-sac ruptures 
and the fetus is discharged into the peritoneum, the va- 
gina, or the large intestine, whence it is born through 
the anus. 

The symptoms of tubal pregnancy are in some cases 
similar in all respects to those of normal uterine preg- 
nancy. In extremely rare cases the woman has reached 
full term in ignorance of any unusual condition. Usually, 
however, the early occurrence of some of the accidents 
of tubal gestation attracts her attention. Before such 



21 



322 A TEXT-BOOK OF DISEASES OF WOMEN. 

accidents or complications arise there are most frequently 
no subjective symptoms to excite any suspicion of the 
peculiar form of pregnancy. Changes in the skin, in the 
nipples, in the nervous and circulatory systems, and in 
the gastro-intestinal tract may resemble those of normal 
pregnancy, and are subject to the same variations. 

Mammary changes accompanied by the secretion of 
milk occur in tubal pregnancy. These changes are, 
however, less pronounced than in uterine gestation. The 
vagina may undergo changes similar to those of normal 
pregnancy; it becomes soft, relaxed, and altered in color, 
and pulsation of vessels may be felt in the walls. 

It should always be remembered, however, that tubal 
pregnancy may occur without the presence of any of the 
signs of pregnancy. Women in perfect health, thought- 
less of pregnancy, have died of acute hemorrhage from a 
ruptured tubal gestation — the first symptom of this con- 
dition. 

The changes in menstruation varv a great deal. Men- 
struation usually ceases when tubal pregnancy begins, 
though not with the same regularity as in normal preg- 
nancy. 

Sometimes menstruation continues for a few months 
and then ceases. In other cases menstruation is arrested 
for the first few months, and occurs with greater or less 
regularity during the latter months of pregnancy. There 
may be an irregular discharge of blood throughout the 
whole course of gestation. 

In the blood discharged from the uterus there may often 
be found pieces of decidual tissue of various size. Some- 
times the whole decidual membrane of the uterus may 
be expelled in one mass. In any suspected case the blood 
should always be carefully examined for such decidual 
membrane. All shreds of tissue should be submitted to 
careful microscopic examination. The woman should be 
questioned in regard to the passage of such tissue before 
she came under medical supervision. 

The woman often complains of periodical pains occur- 



TUBAL PREGNANCY. 323 

ring in the hypogastrium and in the pregnant tube. 
They usually appear after the second month, though they 
may begin earlier. These pains are thought to be caused 
by the contractions of the uterus and the gestation-sac. 

The abdominal enlargement in extra-uterine pregnancy 
differs in several respects from that of normal pregnancy. 
It is usually most marked on one side of the abdomen, 
especially during the first five or six months. 

Toward the end of gestation the enlargement becomes 
more symmetrical in the abdomen, and resembles closely 
that of normal pregnancy. 

In tubal gestation, on account of the higher position 
of the tube, bulging of the abdominal wall is likely to 
appear somewhat earlier than in normal pregnancy. The 
abdominal enlargement in tubal pregnancy does not fol- 
low the same uniform progress that is characteristic of 
uterine pregnancy. 

Fetal movements take place, and fetal heart-sounds are 
heard as in normal pregnancy. 

Bimanual examination made before rupture of the tube 
will reveal the tubal enlargement, the shape of the tube 
depending, of course, upon the position of the tubal 
pregnancy. The tubal enlargement is said by Veit to 
have a characteristic soft feel, distinct from the hard oi 
fluctuating enlargements of other forms of tubal disease. 

After rupture the distinct tubal tumor disappears, and 
the examiner feels a mass lying to one side of or behind 
the uterus. The enlarged tube may be felt merged in 
this mass. 

If pregnancy continues after rupture, the fetal move- 
ments may be felt and ballottement may be obtained. The 
cervix is found to be somewhat softened; the os may be 
patulous; the uterus is soft and enlarged. The uterine 
enlargement, however, is not of the same rounded shape 
as the pregnant uterus, and the size is much less than 
that of corresponding periods of normal pregnancy. 

It is of great importance to study the symptoms of the 
accidents of tubal pregnancy. As has already been said, 



324 A TEXT-BOOK OF DISEASES OF WOMEN. 

it is usually the accident of rupture that first directs the 
woman's attention to the abnormal condition. 

The symptoms depend upon the seat of rupture. Rup- 
ture of the tube into the broad ligament is a much less 
serious accident than rupture into the peritoneal cavity. 

If the rupture into the broad ligament is sudden, the 
woman complains of sudden acute pain in the affected 
side. The pain may extend to the back and throughout 
the pelvis. The intensity and extent of the pain depend 
oh the amount of blood that escapes. Sometimes only a 
small hematoma is found in the broad ligament; at other 
times the blood burrows around the rectum, and symp- 
toms of pressure may arise. Difficult defecation may 
follow. Retention of urine may occur. 

The woman suffers from shock, and may become some- 
what anemic. 

Bimanual examination reveals the condition. The 
broad ligament will be found filled with a tense mass that 
bulges into the vagina. The uterus is pushed to one side. 
The mass may extend behind the uterus and surround 
the rectum. The upper outlines felt by the abdominal 
hand are ill defined. 

The loss of blood from simple rupture into the broad 
ligament is not often sufficient to cause death. The fetus 
may continue to develop, however, and secondary rup- 
ture into the peritoneal cavity may occur. 

Rupture of the tube or of the gestation-sac into the 
peritoneal cavity is a very fatal occurrence. In the 
majority of cases death from hemorrhage occurs within 
twenty-four hours. 

Unless the ovum plugs the rent in the tube, there is 
nothing to arrest the hemorrhage. 

The woman is seized with sudden pain in the side, 
often described as the sensation of "something giving 
away." She suffers from faintness, acute anemia, nau- 
sea, vomiting, and collapse. As in other cases of acute 
anemia, there may be delirium and convulsions. 

Bimanual examination made after intraperitoneal rup- 



TUBAL PREGNANCY. 325 

ture reveals an indefinite fulness or a yielding mass in 
the pelvis behind the uterus. The blood free in the 
peritoneal cavity coagulates slowly, and the fluid blood 
or soft unrestrained clots are often very difficult to pal- 
pate. For this reason, at first the examiner can feel 
only an ill-defined fulness in the pelvis. If the woman 
survives and the mass of blood becomes more solid, it 
may then be distinctly palpated as a solid mass behind 
the uterus, bulging into the vagina, and extending up 
into the abdomen. Though the hematocele may at first 
be difficult to define, yet the enlarged tube may usually 
be palpated, and the ovum may sometimes be felt in the 
midst of the ill-defined mass of blood. 

As has already been said, in rare cases rupture may 
occur intraperitoneally or into the broad ligament with- 
out producing any of the severe symptoms just described. 
The fetus continues to develop, and the woman will be 
ignorant that rupture has ever occurred. Between the 
two extremes there are all degrees of severity. 

In tubal abortion the symptoms resemble those of 
intraperitoneal rupture. 

If the fetus dies within the tube, the symptoms be- 
come those of hematosalpinx or other form of tubal 
disease. 

Diagnosis. — The diagnosis of tubal pregnancy is not 
often made before rupture, because there are usually no 
symptoms that direct the woman's attention to the ab- 
normality of her condition. Very often she thinks that 
she is normally pregnant. 

If opportunity is given for examination before rup- 
ture, the diagnosis may sometimes be made. The 
woman presents the signs of pregnancy. The uterus 
may be slightly enlarged, though not of the size or 
shape normal for the stage of pregnancy. There is 
a soft tubal tumor. 

Immediately after rupture the diagnosis of the condi- 
tion must be made from a study of the previous history, 



326 A TEXT-BOOK OF DISEASES OF WOMEN. 

from the present subjective symptoms, and by bimanual 
examination. 

If a woman who had thought herself pregnant is sud- 
denly seized with pain in the side, followed by anemia 
and shock, the suspicion of extra-uterine pregnancy 
should be aroused. If bimanual examination reveals 
the hematoma or hematocele in the pelvis, with tubal 
enlargement, the diagnosis may be made. Pelvic hema- 
toma and hematocele are in nearly all cases caused by 
tubal pregnancy. 

If the woman survives the rupture and the fetus con- 
tinues to develop, the diagnosis becomes easier the more 
advanced is the case. 

It must be remembered that amenorrhea is not as 
general in tubal as in uterine pregnancy. The woman 
often gives the history of irregular bleeding, or of arrest 
for a few periods and then recurrence of menstruation. 
Such experience may lead her to seek medical advice 
even before rupture. 

The intermitting attacks of pain that are sometimes 
felt in the affected tube may also cause her to seek medi- 
cal advice. 

A history of the discharge of membrane or of shreds 
of membrane is of great value. If opportunity is afforded 
for examination of such shreds, and decidual cells are 
found, and if uterine pregnancy may be excluded, there 
is very, strong evidence that any mass in the pelvis is an 
extra-uterine gestation. 

It has been advised to curette the uterus for diagnosis 
in order to determine the decidual character of the lining 
membrane. This is good advice if the operation is per- 
formed with great care and if we can with certainty ex- 
clude the possibility of uterine pregnancy. If followed 
indiscriminately, numbers of abortions w r ould be pro- 
duced. Uterine pregnancy has often been mistaken for 
tubal pregnancy. The mistake is likely to occur when 
the fundus is drawn to one side or is retroflexed. Uterine 



TUBAL PREGNANCY. 3 2 7 

pregnancy may occur with tubal enlargement from other 
cause than tubal pregnancy. 

In conclusion, the diagnosis of tubal pregnancy before 
the presence of a fetus can be ascertained is based on the 
following considerations: The symptoms of pregnancy; 
a tubal or pelvic tumor; a slightly enlarged though not 
pregnant uterus; discharge of decidual tissue from the 
uterus; the history of the woman pointing to menstrual 
irregularity, uterine discharge of shreds, history of pre- 
vious tubal rupture. 

Treatment. — The treatment of tubal pregnancy is 
operative. It may be considered under the following 
heads: Before primary rupture; At the time of rupture; 
After rupture. 

Before Primary Rupture. — If the physician is so fortu- 
nate as to recognize a tubal pregnancy before primary 
rupture, he should without delay remove the affected 
tube and the contained ovum. The operation is simple, 
is attended by no more danger than that accompanying 
an ordinary salpingo-oophorectomy, and the woman is 
saved the imminent dangers associated with a developing 
tubal pregnancy. There are no circumstances under 
which it is proper to follow an expectant treatment. 

Most of the cases of unruptured tubal pregnancy that 
have been operated upon were not recognized until the 
abdomen had been opened. The operation was per- 
formed under the diagnosis of pyosalpinx, hematosal- 
pinx, or some other tubal disease. The cases show the 
value of the general rule to operate without delay for 
all gross diseases of the tubes. 

At the Time of Rupture. — Many cases of tubal preg- 
nancy are first seen at the time of rupture. In such cases 
celiotomy should be performed without delay. The con- 
dition is most urgent in intraperitoneal rupture, but it is 
the safest rule to operate immediately, whether the rup- 
ture be intraperitoneal or extraperitoneal. It is unwise 
to wait for reaction. The physical depression in such 
cases is due more to hemorrhage than to shock, and it is 



328 A TEXT-BOOK OF DISEASES OF WOMEN. 

in accord with general surgical principles to arrest hem- 
orrhage at once. 

Rupture usually takes place before the twelfth week, 
and the whole product of conception, with the tube, may 
readily be removed. Hemorrhage usually ceases as soon 
as the proximal and distal ends of the ovarian artery are 
ligated. The ligatures may be placed about the ovarian 
artery, at the pelvic wall, and at the uterine cornu, as the 
first steps of the operation, before any attempt is made to 
remove the mass. It may be necessary to close the rent 
in the broad ligament by a series of sutures. 

After Rupture. — If the woman survive, and is first 
seen after primary rupture, one of two conditions will be 
present — a destroyed or a developing extra-uterine preg- 
nancy. If the fetus has died and gestation has ceased, 
the woman is exposed to the various dangers that attend 
the presence of such a foreign body in the abdomen. If 
the fetus has died during the earlier months, it may have 
been absorbed and spontaneous cure may take place. 
Even a dead full-term fetus has been carried in the abdo- 
men for years without producing a fatal result to the 
mother. It seems safest, however, in all such cases to 
operate as soon as the condition is recognized. The rules 
of abdominal and pelvic surgery apply to such cases. 
The placenta of a dead fetus may be removed without 
fear of uncontrollable hemorrhage. 

If the woman is seen after primary rupture, with a de- 
veloping gestation, the case presents much more serious 
dangers. These dangers lie in the placenta. If the 
pregnancy has not advanced beyond the fourth month, it 
is usually possible to remove the whole of the gestation- 
sac, the embryo, and the placenta without uncontrollable 
hemorrhage. The ovarian, and if necessary the uterine, 
arteries may be ligated, and the placenta may be removed 
in one mass. The cavity of the broad ligament may be 
obliterated by buried sutures. 

If the gestation has advanced beyond the fourth month, 
it is often impossible to remove the placenta without fatal 



TUBAL PREGNANCY. 329 

hemorrhage. Many women have bled to death from the 
attempt. The operator sometimes incises the placenta as 
he enters the gestation-sac, and is obliged to proceed with 
its removal. In other cases he starts to remove it, and 
finds, too late, that the hemorrhage is beyond his control. 
In the advanced months of pregnancy the sac and the 
placenta may become adherent to any of the abdominal 
or pelvic viscera and to the large vessels. Hemorrhage 
cannot be controlled, as in the earlier months, by liga- 
tion of the ovarian and uterine arteries. The result in 
these cases is determined by the ability of the operator. 
A full-term living child, the whole sac, and the placenta 
have been successfully removed. If the attachments are 
such that the surgeon considers it unsafe to attempt the 
removal of the sac and the placenta, the sac should be 
incised and the fetus should be removed, the cord being 
divided between two ligatures; the sac should be sutured 
to the abdominal incision; the cord should be drawn 
through the opening, and the sac packed with gauze. At 
the end of four or five days the gauze pack may be re- 
moved, under anesthesia if necessary, and the placenta 
may be taken away. There is very much less risk of 
hemorrhage after the lapse of a few days. Some opera- 
tors prefer to allow the placenta to come away spontane- 
ously. This is sometimes necessary. 

It will be seen, from this consideration, that the treat- 
ment of all varieties of ectopic gestation is operative, and 
that the sooner the operation is performed the better for 
the patient. Consideration for the life of the child should 
have no influence in determining the time of operation. 

Ovarian Pregnancy. — The possibility of the implan- 
tation and development of the fertilized ovum in the 
Graafian follicle has been denied by many authorities. 
It seems probable, however, that such a form of pregnancy 
does very rarely occur. The cause of ovarian pregnancy 
is thought to be due to some disturbance of the normal 
process of ovulation, whereby the ovum fails to leave the 
ruptured follicle and is there fertilized and developed. 




CHAPTER XXVII. 
DISEASES OF THE OVARIES. 

Anatomy. — The ovaries vary a good deal in size, with- 
in the limits of health, in different individuals. It is 
unusual to find the two ovaries in the same person exactly 
alike in size, shape, and appearance. 

The size, shape, and appearance of the ovary change 
at the different periods of life. In the new-born child 
uterus the ovary is elongated and 

convoluted lies parallel to the Fallopian 

Tube r ... r 

tube (Fig. 158). In rare 
cases this infantile shape of 
the ovary may persist 
throughout life. 
cervix Fringes J The general shape of the 

Fig. 158.— uterus, tube, and ovary ma t U re ovary is oval. The 

of a child one month old (Sutton). 

v ' average measurements are — 
long axis, 3 to 5 centimeters; breadth, 2 to 3 centimeters; 
thickness, 12 millimeters; weight, 100 grains. These 
measurements are subject to great variations. Henning's 
table of measurements shows that the ovary of the mul- 
tipara is no larger than that of the virgin. 

After the menopause the ovaries shrink a great deal in 
size, sharing in the general atrophy of all the reproduc- 
tive organs. The ovary of an old woman may weigh but 
15 grains. 

The healthy ovary is of a pinkish pearly color. On its 
surface are seen small bluish areas that mark the position 
of unruptured or of recently ruptured ovarian follicles. 
The ripening follicles project somewhat from the surface 

of the ovary, and the old ruptured follicles are marked by 

330 



DISEASES OF THE OVARIES. 331 

scars which in time cover and render irregular the whole 
surface of the ovary (Fig. 159). 

The surface of the ovary becomes more irregular and 
wrinkled after the menopause. The follicles disappear, 
until finally nothing is left but a mass of fibrous tissue 
and a few blood-vessels. 

The ovary lies in the posterior layer of the broad liga- 
ment. It is attached by this connection with the broad 



Utero-ovarian 
Ligament 




Cervix 

Fig. 159. — Ovary (natural size), with the Fallopian tube in relative position 

(Sutton). 

ligament and by the ovarian and infundibulo-pelvic liga- 
ments. 

The ovarian ligament extends from the inner end of 
the ovary to the angle of the uterus immediately below 
the origin of the Fallopian tube. This ligament varies 
in length from 3 to 5 centimeters. It is shortest in the 
virgin, and longest in the multiparous woman. The 
ligament consists of a fold of peritoneum containing 1111- 
striped muscular fiber from the uterus. 

The infundibulo-pelvic ligament is that part of the 



332 A TEXT-BOOK OF DISEASES OF WOMEN. 

upper margin of the broad ligament lying between the 
distal end of the Fallopian tube and the pelvic wall. It 
is about 2 centimeters in length. The length is greatest 
in the multiparous woman. 

The position of the ovary is maintained by its attach- 
ments and by its own specific gravity. The considera- 
tions that have been discussed in regard to the position 
of the uterus also apply here. 

The blood-vessels are the utero-ovarian arteries and the 
ovarian arteries and veins. The ovarian artery is homol- 



--, 






1^ 


■ 


./*'■•/ 






X- 



Fig. 160. — View of the posterior surface of the uterus, Fallopian tubes, 
ovaries, and broad ligaments. The infundibulo-pelvic ligament is shown on 
the left (Dickinson). 



ogous to the spermatic artery in the male. The course 
of the ovarian veins has an important influence upon 
some pathological conditions of the ovaries. 

The right ovarian vein enters the inferior vena cava at 
an acute angle, and at the junction of the two there is a 
very perfect valve. 

The left ovarian vein enters the left renal vein at a 
right angle: there is no valve on this side. This ana- 
tomical difference affords a probable explanation of the 
greater tendency to congestion and prolapse of the left 
ovary. 



DISEASES OF THE O VARIES. 333 

The ovary is composed of connective tissue which sur- 
rounds the Graafian follicles, blood-vessels, lymphatics, 
nerves, and unstriped muscular fibers. The posterior 
portion, or the free portion of the ovary, is covered with 
the germinal epithelium, or modified peritoneum, which 
is continuous with the peritoneum of the broad liga- 
ment. 

The ovary is divided into two portions, which present 
distinct anatomical, physiological, and pathological dif- 
ferences. 

The obphoron is the egg-bearing portion of the ovary. 
It corresponds to the free border of the gland. 

The paroophoron corresponds to the hilum of the ovary 
— that portion in relation with the broad ligament. 

The paroophoron contains no ovarian follicles. It is 
composed of connective tissue and numerous blood-ves- 
sels. In the paroophoron of young ovaries remnants of 
gland-tubules — vestiges of the Wolffian body — may be 
found. 

Accessory ovaries have been described by several 
writers, and their existence has often been assumed to 
account for the persistence of menstruation after a sup- 
posed complete salpingo-oophorectomy. It is very doubt- 
ful if a true accessory ovary has ever been found. Bland 
Sutton says: "As the evidence at present stands, an ac- 
cessory ovary quite separate from the main gland, so as to 
form a distinct organ, has yet to be described by a com- 
petent observer." It is probable that the bodies that 
have been described as accessory ovaries have been more 
or less detached portions of a lobulated ovary, or small 
fibro-myomatous tumors of the ovarian ligament. Ab- 
dominal surgeons have had opportunity of examining 
thousands of ovaries at operation, and yet I know of no 
one who has come across a third ovary. 



CHAPTER XXVIII. 
DISEASES OF THE OVARIES (Continued). 

HERNIA OF THE OVARY. 

Hernia of the ovary may take place through the in- 
guinal ring. Congenital hernia of the ovary is extremely 
rare. Bland Sutton says that there is no properly 
authenticated case. Notwithstanding the frequency of 
congenital hernia in infants, the ovary has not been 
found in the hernial sac at birth. 

In cases that have been reported as congenital hernia 
of the ovaries the structures have, on microscopical ex- 
amination, been found to be testicles, the individual 
being hermaphroditic. 

Acquired hernia of the ovary is of not infrequent oc- 
currence. The ovary may occupy the hernial sac alone 
or along with other structures. 

Ovulation may occur normally, and conception may 
take place. A true corpus luteum has been found in an 
ovary contained in a hernial sac. 

The ovary may remain in the inguinal ring or may 
pass into the labium majus. In some cases no trouble 
whatever arises from this displacement. Hernia of the 
ovary has been found accidentally at autopsy, having 
been entirely overlooked during life. In other cases 
swelling and severe pain may be experienced at the men- 
strual periods. 

The ovary is exposed to the dangers of congestion and 
inflammation. Adhesions may result, and suppuration 
has occurred. In such cases the symptoms of ovaritis 
are present. 

The diagnosis of hernia of the ovary is made from 
palpation of the gland; from the determination, by bi- 

334 



DISEASES OF THE OVARIES. 335 

manual examination, of its connection with the uterus; 
from the characteristic sickening pain experienced upon 
pressure; and from the swelling and increased pain at 
the menstrual period. 

The treatment is the same as that applied to hernia 
of any other structure. The hernia should be reduced 
if possible, and retained by a truss; or the ring may be 
closed by radical operation for hernia. If the ovary is 
adherent, operation is necessary before reduction can be 
accomplished. If the ovary is itself grossly diseased, its 
removal may be necessary. 

PROLAPSE OF THE OVARY. 

Prolapse of the ovary is a downward displacement of 
this organ behind the uterus. Various degrees of pro- 
lapse occur, from a slight descent to complete prolapse 
in the bottom of Douglas's pouch. 

There are two general kinds of ovarian prolapse. In 
one the uterus is primarily the displaced organ, and when 
prolapsed, retroverted, or retroflexed, it drags the ovaries 
out of place with it. Such cases have been referred to 
in discussing uterine displacement. If the ovaries are 
not adherent, they usually return to the normal position 
when the uterus is replaced. Similar to this kind of dis- 
placement of the ovary is that which occurs in disease 
of the Fallopian tubes, which, when enlarged, descend 
and drag the ovaries with them. In the other variety 
the displacement is primary in the ovary, and occurs in- 
dependently of any displacement of the uterus or other 
structure to which it is attached. It is such prolapse 
that will be considered here. 

There are various canses of ovarian prolapse. In 
some cases it is probable that the position of the ovaries 
in the bottom of Douglas's pouch is congenital. 

A sudden strain or effort is said to have produced acute 
prolapse of the ovary. 

Anything that increases the weight of the ovary may 



336 A TEXT-BOOK OF DISEASES OF WOMEN. 

cause its descent. Prolonged congestion, inflammation, 
or small ovarian tumors may result in ovarian prolapse. 

Subinvolution is the most frequent cause of ovarian 
prolapse. In pregnancy the ovaries become very much 
enlarged, especially the left one. The ovarian ligament 
and the infundibulo-pelvic ligament become much in- 
creased in length. If, after labor, involution is arrested 
or is incomplete for any reason, the conditions favorable 
for prolapse of the ovary will be present — increased 
weight of the ovary and relaxation and lengthening of 
its attachments. Sometimes the cause of the prolapse is 
in the ligaments alone. The ovary may have returned to 
its normal size, while the ligaments may have remained 
subinvoluted, permitting undue freedom of movement. 

The left ovary is more frequently prolapsed than the 
right. There are two reasons for this difference. As has 
just been said, the left ovary becomes more enlarged dur- 
ing pregnancy, and therefore suffers more from subin- 
volution, and the arrangement of the veins on the left 
side is such that venous congestion is very liable to 
occur. 

When prolapse has existed for a long time, secondary 
changes take place in the ovary as the result of hyper- 
emia, and the condition becomes further aggravated. 

Symptoms. — Slight descent of the ovary very often 
causes no suffering whatever. When, however, the 
ovary is completely prolapsed, lying in the bottom of 
Douglas's pouch, between the posterior wall of the 
vagina and the rectum, well-marked symptoms usually 
arise. 

The woman suffers pain whenever she is in the erect 
position. The pain is increased by walking, probably 
because the ovary is squeezed between the cervix and the 
sacrum. Coitus sometimes causes intense pain. Defeca- 
tion causes pain. The pain begins with the movements 
of the bowels, and often lasts for one or two hours after- 
ward. It is dull and aching in character, and is situated 
in the normal position of the ovary, radiating thence 



DISEASES OF THE OVARIES. 337 

throughout the pelvis and extending down the thighs. 
It frequently produces faintness and nausea. 

The ovarian pain is markedly increased at the men- 
strual periods. 

The general and reflex disturbances produced by pro- 
lapse of the ovary are often very pronounced. There 
may be headache, indigestion, hysteria, and great mental 
depression. A reflex pain is often felt in the breast on 
the same side with the affected ovary. 

Bimanual examination usually reveals the condition. 
The prolapsed ovary may readily be felt by the vaginal 
finger. If the finger is introduced high up behind the 
cervix, and is then turned with the palmar surface back- 
ward, the ovary may be caught between the finger and 
the sacrum. The irregular surface of the ovary, due to 
the prominent vesicles and the old scars, may often be 
felt. When the ovary is pressed upon there is a charac- 
teristic sickening feeling experienced by the woman. 
Sometimes she cries out with intense pain even upon the 
gentlest pressure on the ovary. After witnessing such 
pain the physician realizes the extent of the suffering ex- 
perienced in walking, at coitus, and at defecation. If 
the ovary is not adherent, it may slip from the examin- 
ing finger, and perhaps may not be felt again until a 
subsequent examination, after it has returned to its pro- 
lapsed position. 

A large prolapsed ovary has often been mistaken for 
the fundus uteri, and has caused the diagnosis of retro- 
flexion to be made. This mistake will not occur if the 
examiner determines the real position of the uterus by 
palpation or by the sound. The uterus may usually be 
moved independently of the prolapsed ovary. 

Treatment. — The treatment of ovarian prolapse de- 
pends upon the cause of the condition. Prolapse of the 
ovary caused by uterine displacement is usually cured by 
the treatment that restores the uterus to its normal posi- 
tion. 

Prolapse of the ovary accompanying tubal disease and 
22 



33% A TEXT-BOOK OF DISEASES OF WOMEN. 

prolapse caused by small ovarian tumors demand opera- 
tion and removal of the tube and ovary. 

When the ovary is not adherent, it may sometimes be 
restored to its normal position, or at least be considerably 
elevated, so that the suffering is much relieved, by pla- 
cing the woman in the knee-chest position and opening 
the vagina. In this position all the pelvic structures are 
carried upward. 

A pledget of cotton or wool placed back of the cervix, 
in the posterior vaginal fornix, will often give great 
temporary relief. The cotton may stay in the vagina for 
twenty-four to forty-eight hours. 

The woman should be advised to assume the knee- 
chest position, allowing air to enter the vagina by intro- 
ducing the nozzle-piece of the vaginal syringe, once or 
twice daily. The best time is immediately before retir- 
ing at night, and she should afterwards sleep as much as 
possible on the side, in the Sims position. She should 
remain in the knee-chest position for several minutes — 
until tired. 

In addition to this treatment, the pelvic congestion 
should be relieved by continuous use of saline laxatives, 
by hot-water vaginal douches, and by occasional applica- 
tions of Churchill's tincture of iodine to the vaginal 
vault, and the use of the glycerine tampon. If the pro- 
lapse has been caused by subinvolution of the ovary and 
its attachments, such treatment may ultimately result in 
cure. The enlarged ovary diminishes in size and weight, 
and its ligaments contract and regain tonicity. 

Subinvolution of the uterus is often also present. This 
condition should be treated as has already been advised. 

In many cases of ovarian prolapse there have taken 
place in the ovary secondary changes that resist such 
treatment even when most conscientiously applied. The 
physician is then driven to the operation of oophorectomy 
as the only method of relieving the intolerable suffering. 
This operation should never be performed, however, until 
other milder treatment has been carefully tried, and un- 



DISEASES OF THE OVARIES. 339 

less the suffering of the woman incapacitates her for the 
duties of life. 

In some cases in which the ovary is not itself grossly 
diseased it may be possible to avoid oophorectomy, and 
to correct the displacement by attaching the ovary by 
suture to the upper margin of the broad ligament, or by 
shortening the infundibulo-pelvic ligament by suture. 
If the ovary has become adherent in Douglas's pouch, 
the condition can be relieved only by operation — celi- 
otomy, and usually oophorectomy. 

A variety of pessaries have been invented for the relief 
of ovarian prolapse. They are of but little, if any, use. 
In many cases the pressure of the pessary upon the ovary 
renders its employment impossible. No pessary will 
cure a simple prolapse of the ovary. The cases in which 
the pessary does good are those in which there is a pri- 
mary uterine displacement. 

INFLAMMATION OF THE OVARY; OOPHORITIS OR 
OVARITIS. 

Acute Oophoritis. — In acute oophoritis the inflam- 
mation may begin on the surface of the ovary (peri- 
oophoritis) and extend inward, or it may begin in the 
ovary itself. When the disease is caused by extension 
of the inflammation from the tubes, it usually begins as 
a perioophoritis. Both the follicular and interstitial por- 
tions of the ovary may be affected. When the inflam- 
mation is confined chiefly to the ovarian follicles, it is 
said to be parenchymatous; when the connective tissue is 
chiefly affected, it is called interstitial oophoritis. In 
acute inflammations all portions of the ovary are usually 
involved at one time. 

The changes are those that characterize inflammation 
of other glandular structures. The whole organ becomes 
swollen, hyperemic, and edematous. The liquor folliculi 
becomes turbid; the membrana granulosa becomes soft- 
ened and disintegrated. The surface of the ovary may 
be covered with an inflammatory exudate. In severe 
septic cases the whole ovary may become destroyed, or 



34-Q A TEXT-BOOK OF DISEASES OF WOMEN. 

one or more ovarian abscesses may be formed. In less 
severe cases the inflammation subsides before suppuration 
takes place, or goes on to chronic oophoritis. 

The usual cause of acute oophoritis is extension of in- 
flammation from the Fallopian tube. 

Acute oophoritis may also occur as the result of septic 
infection carried by the lymphatics of the uterus. The 
disease is not uncommon in puerperal sepsis. Here it 
often forms but a minor part of a general fatal infection. 

Gonorrhea may cause oophoritis in a similar way. 

Acute suppression of menstruation is said to result in 
inflammation of the ovaries. 

Acute rheumatism and the eruptive fevers may produce 
oophoritis. The disease of the ovaries is often overlooked 
during the acute attack, while the attention of the physi- 
cian is engaged by the general affection. These diseases, 
occurring in childhood, are the probable causes of some 
of the damaged and chronically inflamed ovaries with 
which women suffer in later life. To these diseases also 
are to be attributed many cases of arrested development 
of the sexual apparatus, the phenomena of which appear 
only after menstruation has begun. The ovarian dis- 
ease in these cases may be very insidious. Decided 
microscopic changes have been found in the ovarian 
follicles in scarlet fever, though to the naked eye the 
gland was unchanged. 

The symptoms of acute oophoritis are very often masked 
by those of accompanying affections, such as salpingitis 
and puerperal sepsis. 

There may be a chill, followed by fever, nausea, and 
vomiting. 

The pain is that which characterizes any local pelvic 
inflammation. It is most intense in the ovarian regions. 

Bimanual examination may reveal the enlarged, tender 
ovaries, which are very often prolapsed behind the uterus. 

The greatest gentleness should always be observed in 
making a vaginal examination in any case of inflamma- 
tion of the pelvic structures, not only to avoid inflicting 



DISEASES OF THE OVARIES. 341 

unnecessary pain, but because a much more satisfactory 
examination can be made if the woman does not fear and 
resist the examiner. 

Treatment. — The treatment of acute oophoritis is ex- 
pectant. It is similar to that already advised for acute 
salpingitis. The physician should prescribe absolute rest 
in bed; hot fomentations over the abdomen; saline laxa- 
tives; and warm vaginal douches of sterile water if the 
pain is not increased by them. 

If suppuration occurs, immediate laparotomy with re- 




FlG. 161.' — Cystic ovary. 

moval of the diseased structures should be practised. If 
the acute inflammation subside, subsequent operation 
may be necessary for the chronic inflammation. 

Chronic Oophoritis. — Chronic oophoritis, like the 
acute form, may be either parenchymatous or interstitial. 
Usually both the connective tissue and the ovarian folli- 
cles are involved. The disease is usually bilateral. The 
tunica albuginea may become much thickened, and adhe- 
sions may form between the ovary and the adjacent struc- 
tures. 

In practice we find chronic oophoritis in two forms: 



342 



A TEXT-BOOK OF DISEASES OF WOMEN. 



The ovary may be cystic, filled with a number of cysts 
of varying size up to that of a marble (Fig. 161). These 
cysts are transformed ovarian follicles. The walls are 
thickened, and the ova and the membrana granulosa 
have undergone fatty degeneration and absorption. The 
fluid in the cysts may be clear, cloudy, bloody, or gelat- 
inous. Sometimes the septa are absorbed, and several 
cysts are thrown into one cavity. The connective tissue 
of the ovary is increased in amount. 

The ovary becomes enlarged, though it rarely exceeds 
the size of a hen's egg. 




Fig. 162. — Cirrhotic ovary from an old maid forty years of age. 

It is probable that this form of inflammatory change is 
the origin of some kinds of small ovarian cystic tumors. 

In the other form of chronic oophoritis the interstitial 
changes are most marked. There is a decided increase 
of the connective tissue, and a diminution of the paren- 
chymatous or follicular structures. The ovary is hard 
and cirrhotic, and is of a lighter or paler color than 
normal; the visible ovarian follicles are few; the greater 
part of the ovary appears to be a mass of wrinkled con- 
nective tissue; in some cases the follicular structure is 
confined to but one-quarter of the ovary. The changes 
resemble and are similar to those that take place physio- 
logically in the ovaries of old women (see Fig. 162). 



DISEASES OF THE OVARIES. 343 

Between these two types of cystic and cirrhotic ovaries 
various forms, combinations of the two, may occur. The 
ovary upon one side may be cystic, upon the other cir- 
rhotic. 

The causes of chronic oophoritis are various. The 
condition may persist after the subsidence of acute 
oophoritis. It is usually secondary to salpingitis. There 
are very few cases of chronic salpingitis that are not ac- 
companied by some form of oophoritis. The disease 
may be chronic from the beginning. It may develop 
slowly from septic or gonorrheal infection from the 
uterus. It may result from subinvolution or prolapse of 
the ovary. 

It may result from immoderate sexual irritation, and 
from unnatural gratification of the sexual impulse. 

It seems probable also that chronic ovaritis may occur 
as the result of celibacy or sterility. The unceasing 
menstrual congestions of the virgin or the sterile woman, 
which, as has already been pointed out, seem to predis- 
pose the woman to fibroid changes in the uterus, seem 
likewise to develop the growth of connective tissue in 
the ovary. Virgins between the ages of thirty and forty 
often present hard cirrhotic ovaries with decided diminu- 
tion of the follicular elements. The condition is often 
associated with a fibroid state of the uterus, this organ 
being indurated from interstitial fibroid deposit, or pre- 
senting one or more subperitoneal nodules. 

Symptoms. — The most prominent symptom of chronic 
oophoritis is pain. The disease is usually bilateral, and 
the pain affects both ovarian regions; it is, however, 
usually more marked upon the left side. The pain is in- 
creased by the erect position and by exercise, defecation, 
and coitus. Pain at defecation and coitus is most marked 
when ovarian prolapse accompanies the inflammation. 

The pain is increased at the menstrual period. It is 
most intense immediately before and at the beginning of 
the flow. If the bleeding is profuse, the pain is often 
relieved. 



344 A TEXT-BOOK OF DISEASES OF WOMEN. 

Menorrhagia often accompanies chronic oophoritis, and 
seems to occur chiefly with the cystic variety of the dis- 
ease. As most cases of oophoritis are accompanied by 
endometritis and salpingitis, it is difficult to determine 
how important a part in the production of the menor- 
rhagia is played by the ovarian disease. Reflex pain in 
the region of one or both breasts, usually the left, is often 
complained of. 

The reflex disturbances caused by chronic oophoritis 
form a very important part of the woman's suffering. 
Loss of appetite, digestive disturbances, nausea, and 
vomiting occur. Hysteria, profound mental depression, 
and various cerebral derangements take place. Sterility 
may be caused by chronic oophoritis if the ovarian cap- 
sule becomes so thickened that rupture of ovarian follicles 
cannot take place. 

Bimanual examination should be performed with great 
gentleness. The condition of the ovary may be most 
satisfactorily determined in those cases in which the 
ovarian lesion is the chief trouble and in which the tubes 
and other pelvic structures are not coincidently inflamed. 
If the ovary is felt, it is found to be very tender and usu- 
ally enlarged. In cases of long-standing interstitial in- 
flammation the ovary may be below the usual size. Pal- 
pation is very easy if the ovary is prolapsed in Douglas's 
pouch. 

Chronic oophoritis rarely recovers spontaneously. The 
woman may have periods of relief, but the symptoms may 
all recur after some indiscretion or unusual exercise. 
Suffering usually diminishes, and may in time cease, after 
the menopause, when atrophy takes place and menstrual 
congestions have stopped. 

Treatment. — Chronic oophoritis usually requires oper- 
ative treatment (salpingo-oophorectomy), because it is 
associated with disease of the tubes. In other cases a 
great deal may be accomplished without operation, and 
the woman may be tided over the period of menstrual 
life until permanent relief is secured at the menopause. 



DISEASES OF THE OVARIES. 345 

This palliative treatment is usually applicable, how- 
ever, only to those women who are not dependent for a 
living upon their own labor. It is best to begin the treat- 
ment by putting the woman to bed for one or two months; 
to administer daily massage; to maintain mild purgation 
with saline purgatives; to make, once a week, applica- 
tions of Churchill's tincture of iodine to the vaginal 
vault, followed by the glycerin tampon; and to give hot- 
water vaginal injections twice a day. 

If there is any disease of the uterus, such as laceration 
of the cervix or endometritis, this should be treated first. 

After the woman leaves her bed the douches, saline 
laxatives, and vaginal applications should be continued. 
Absolute rest in the recumbent posture should be pre- 
scribed at the menstrual periods, and at other times if 
the ovarian pain becomes severe. Coitus should be for- 
bidden during the treatment. If the woman is unable 
to begin the treatment by prolonged rest, the subsequent 
part of the treatment advised here may be followed. 

This treatment always does good for a time. Unfortu- 
nately, its results are not often permanent. The old pain 
and suffering return as soon as the woman ceases to be 
under medical care. If the inflammatory changes have 
become well established, no permanent good results from 
any medical treatment. This is especially true in those 
cases in which the original causative state of things con- 
tinues after treatment is given up. If the cirrhotic 
ovaries are the result of celibacy, medicine can be but 
palliative. 

Working-women are unable to obtain the proper medi- 
cal treatment, especially when the prospect of cure is 
doubtful, and therefore, if their suffering incapacitates 
them, must be subjected to the operation of oophorec- 
tomy. 

In any case oophorectomy should be advised if the suf- 
fering persists after carefully tried medical treatment. 



346 A TEXT-BOOK OF DISEASES OF WOMEN. 

APOPLEXY OF THE OVARY. 

Hemorrhage may take place either into an ovarian 
follicle, in which case it is called follicular hemorrhage; 
or it may take place into the ovarian stroma; to this 
condition the term ovarian apoplexy is applied. 

Hemorrhage into the follicles is usually small in 
amount, the distended follicle rarely exceeding the size 
of a hickory-nut. In case of cystic degeneration of the 
ovary small blood-filled cysts may be present, formed by 
the fusion of several follicular cysts. Occasionally the 
amount of blood in the follicle is enough to cause its rup- 
ture. If the follicle should rupture into the peritoneum, 
a small hematocele would result. If the follicle ruptures 
into the ovarian stroma, ovarian apoplexy occurs. 

Follicular hemorrhage and ovarian apoplexy are most 
liable to occur during the congestion of a menstrual 
period. 

Such hemorrhages are not infrequent in the acute 
fevers and in scurvy. The symptoms of the condition 
are in no way characteristic. If the exact state of the 
ovary were known from previous examination, follicular 
hemorrhage or apoplexy might be suspected from the de- 
tection of a sudden ovarian enlargement and pain unac- 
companied by symptoms of inflammation. 

The blood is usually absorbed, and unless some accom- 
panying disease of the ovary is present, spontaneous re- 
covery will result. 

OVARIAN HYDROCELE. 

Ovarian hydrocele is a rare disease, the true nature of 
which has been explained by Bland Sutton. Most of 
the cases that have been reported have been mistaken 
for tubo-ovarian cysts. The tubo-ovarian cyst has 
already been described. It is a cyst that results from in- 
flammatory disease of the tube, and is formed by the 
union of the cavities of a closed Fallopian tube and a 
follicular cyst in the ovary. 



DISEASES OF THE OVARIES. 347 

Ovarian hydrocele has a different origin. To understand 
it a brief reference to the relation between the ovary and 
the broad ligament is necessary. I quote from Bland 
Sutton: "The ovary projects from, and is invested by 
the posterior layer of the broad ligament. When the 
parts are examined in situ, the ovary will be found to lie 
in or upon the edge of a shallow recess in the mesosal- 
pinx. This recess is the ovarian sac (Fig. 163). It 
varies in depth; in many it is small and inconspicuous, 
whilst in others it is sufficiently deep to accommodate 



Fringes 

{fimbria) 



Tubo-ovarian 
Ovarian Ligament 

sac 



liter o- ovarian 
Fundus Ligament 



Uterus 




Fig. 163. — Left Fallopian tube from an adult (after Richard). 

the entire ovary. In the virgin the ampulla of the tube 
falls over the mouth of this recess and conceals the ovary. 
This relation of parts is usually disturbed in the first 
pregnancy. ' ' 

Tait 1 says: " In a few exceptions I have seen a cre- 
scentic double fold of the posterior layer of the broad 
ligament pass down behind the ovary, covering it like 
the hood of a ' Nepenthes ' gland. In all such cases the 
women have been sterile, probably because this hood has 
prevented the application to the ovary of the opening of 

1 Diseases of the Ovaries, 1883, p. 6. 



348 A TEXT-BOOK OF DISEASES OF WOMEN. 

the oviduct. I have seen this arrangement give great 
trouble in the removal of small ovaries." In some 
animals the ovarian sac is much better developed than in 
the human female. In the hyena it forms a complete 
tunic to the ovary, the cavity of the sac communicating 
with the peritoneum by a small opening. In rats and 
mice the sac is complete, and the Fallopian tube com- 
municates with the ovarian sac, but not with the general 
peritoneal cavity. 

Ovarian hydrocele occurs in women when the abdom- 
inal ostium of the Fallopian tube opens into a well- 
formed ovarian sac and the common cavity becomes dis- 
tended with fluid. 

Sutton sums up the peculiarities of ovarian hydrocele 
as follows: 

I. The Fallopian tube opens by its abdominal ostium. 
into a sac on the posterior aspect of the broad ligament. 

II. The tube is elongated, dilated, and tortuous, re- 
sembling a retort with a convoluted delivery tube. 

III. As a rule, there is no evidence of inflammation. 
The cyst may suppurate should the tube become affected 1 
with salpingitis. 

IV. In small cysts the ovary will be found projecting 
on the floor of the sac. In larger specimens it will be 
incorporated with the wall of the sac, and in very large 
specimens it is unrecognizable. 

An ovarian hydrocele may attain considerable size. A 
case has been reported in which three pints of straw- 
colored fluid were found in the cyst. An ovarian hydro- 
cele is sometimes intermitting, discharging its contents 
through the tube into the uterus. 

The symptoms of ovarian hydrocele resemble those of 
a small ovarian cyst or a tubo-ovarian cyst. 

The treatment is celiotomy and removal of the tube 
and ovary, or, when practicable, the liberation of the; 
adherent end of the Fallopian tube. 



CHAPTER XXIX. 
CYSTIC TUMORS OF THE OVARY. 

The histogenesis of cystic tumors of the ovary is not 
yet definitely settled. Every structure that enters into 
the composition of the ovary has been supposed to form 
the starting-point of these tumors. There are many clas- 
sifications of ovarian cysts based upon the clinical, struc- 
tural, or genetic features. The classification given here 
seems to me to be the best we have at present for the 
practical physician. 




Fig. 164. — Diagram representing the cyst-regions of the ovary and broad 

ligament. 

Cystic tumors of the ovary may be divided into two 
general classes: 

I. Oophoritic cysts, which originate from the oophoron, 
or the egg-bearing portion of the ovary. 

II. Paroophoritic cysts, which originate in the paro- 
ophoron. 

319 



350 A TEXT-BOOK OF DISEASES OF WOMEN. 
OOPHORITIC CYSTS. 

Cysts of the oophoron may be subdivided into (a) Fol- 
licular cysts; (b) Glandular cysts; (c) Dermoid cysts. 

Follicular Cysts.— Follicular cysts originate in the 
ovarian follicles. If anything occurs to prevent the 
physiological rupture of a mature ovarian follicle, a fol- 
licular cyst may be started. Such cysts begin as reten- 
tion-cysts of the ovarian follicles. 

The condition is usually the result of chronic inflam- 
mation. The formation of new connective tissue in the 
ovarian stroma, the thickening of the tunica albuginea, 




Follicular cyst of the ovary. 



the presence of inflammatory exudate upon the surface 
of the ovary, may all prevent the rupture of the follicles. 
In addition, the inflammatory congestion of the walls of 
the follicle produces an increased exudation into the 
ovisac. 

It seems probable that such inflammatory action may 
also produce cystic distention in the immature follicles 
that are situated remote from the surface of the ovary. 

Follicular cysts may occur at any age, though they are 
most common during the period of sexual activity. The 



CYSTIC TUMORS OF THE OVARY. 351 

follicular cysts may occur in one or in both ovaries; usu- 
ally both ovaries are affected. 

Only one follicle may be involved, or a large number 
of follicles, in different degrees of cystic distention, may 
be found scattered throughout the ovary. 

Frequently one follicle enlarged to the size of a hen's 
egg is observed projecting from the surface of the ovary. 
Sometimes the intervening septa atrophy, and one large 
cavity is formed by the union of two or more cystic 
follicles. 

Follicular cysts of the ovary do not increase indefinitely 
with age. They are limited in growth, and in this re- 
spect differ essentially from the glandular oophoritic 
cysts. They are usually about the size of a hen's egg. 
They rarely attain a size greater than that of the adult 
fist. Exceptional cases have been reported in which the 
ovarian tumor was the size of the adult head. The tumor 
may be composed of one chief cyst-cavity, while the rest 
of the ovary may present a much less marked degree of 
cystic distention; or a large number of follicles may be 
uniformly distended each to the size of a cherry, forming 
an ovarian tumor as large as a child's head. 

When the ovarian follicle becomes distended the walls 
usually increase in thickness and strength. 

The interior of the cyst is smooth. The character of 
the lining membrane varies with the size of the cavity. 
In small cysts it is the membrana granulosa — columnar 
epithelium. In cysts of medium size the cavity is lined 
with stratified epithelium. In the largest cavities there 
may be no epithelium present, the lining membrane be- 
ing fibrous tissue. 

The follicular cyst is usually filled with clear serum 
having a specific gravity of 1005 to 1020. It resembles 
normal liquor folliculi. The fluid may be purulent as a 
result of septic infection, or it may be brown or black 
from the presence of altered blood. Ova are sometimes 
found in follicular cysts of moderate size. Sometimes 
hemorrhage takes place into the follicular cyst, form- 



352 A TEXT-BOOK OF DISEASES OF WOMEN. 

ing a follicular blood-cyst, which may attain the size 
of a man's fist. 

Cyst of the Corpus Luteum. — A variety of the follicular 
cyst is the cyst of the corpus luteum. Such a cyst is 
formed by the degeneration and cystic distention of a 
corpus luteum. These cysts are usually of small size, 
rarely exceeding that of a walnut. The walls are thick 
and of a characteristic light-yellow color. The cavity is 
lined by a delicate membrane. Cysts of the corpus 
luteum are rare in the human female, but are very 
common in some of the lower animals — the cow and the 
mare. 




Pig. 1 66. — Cyst of the corpus luteum, showing the yellow lining membrane (a) ; 
6, small follicular cyst. 

The symptoms caused by follicular cysts are those 
of pressure and ovarian pain. The cyst may become 
impacted and adherent in the pelvis, and may cause 
pressure. The ovarian pain is analogous to that de- 
scribed under Chronic Oophoritis. The pain that ac- 
companies this form of cystic tumor of the ovary is much 
more marked than in the case of the larger kinds of ova- 
rian cyst, which may be unattended by any ovarian pain 
whatever. In some cases follicular cystic disease of the 
ovaries is accompanied by menorrhagia or metrorrhagia 
which is only relieved by oophorectomy. This symptom, 
however, is not usual. 

The diagnosis of the condition is made by bimanual 



CYSTIC TUMORS OF THE OVARY. 353 

examination and by observation of the clinical course of 
the disease. The cystic disease is very often bilateral. 
The ovarian enlargement is slow in development and is 
always limited. A moderate maximum size is reached 
and may persist for years. 

Treatment. — The only curative treatment of follicular 
cystic disease of the ovaries is by operation and removal 
of the tumor. Operation is required only in those cases 
in which the suffering is great. The mere presence of 
the cystic ovary does not demand operation, whether it 
causes physical suffering or not, as in the case of the 
cystic tumors hereafter to be considered. It must be re- 
membered, however, that it is often difficult or impossible 
to make a differential diagnosis between follicular cyst of 
the ovary and a young glandular or papillomatous cyst, 
and it is very much safer in all doubtful cases to adopt 
the operative rather than the expectant plan of treatment. 
If, after the abdomen is opened, the cyst is found to be 
follicular, the ovary need not necessarily be removed. 

If, at the time of operation, the ovary is found to pre- 
sent but one follicular cystic cavity, this may be opened 
and evacuated and part of the wall may be excised. If 
bleeding occurs from the edges of the cyst- wall, it may be 
controlled by whipping with a fine continuous suture of 
silk or catgut. Some operators avoid this bleeding by 
opening the cyst with the cautery-knife. In any case 
the bleeding is usually slight if a thin portion of the cyst- 
wall is selected for the incision. If the ovary is filled 
with a number of cystic cavities, it is safest to remove the 
whole organ. If the woman be young and anxious for 
children, the portion of the ovary that contains the cysts 
may be excised and the wound in the ovary closed by 
sutures of fine catgut. Simple puncture of the cysts does 
no good. The conservative operation is especially desir- 
able in case both ovaries are diseased. When but one is 
affected, the surgeon need not hesitate so much before 
performing oophorectomy. 

If, as is very often the case in cystic disease of this 
character, the Fallopian tubes are found closed bv iuflam- 

23 



354 A TEXT-BOOK OF DISEASES OF WOMEN. 

matory adhesions, salpingo-oophorectomy is usually indi- 
cated. 

Glandular Cysts.— Glandular cysts are also called 
multilocular ovarian cysts or ovarian adenomata. 

It was formerly thought that all ovarian cysts originated 
in the Graafian follicles. This view has now been given 
up by most pathologists. The follicular cysts that have 
just been described never attain a large size, and run a 
distinctly different course from the glandular cysts now 
under consideration. 

The glandular cysts probably originate from the tubes 
of Pfliiger. It will be remembered that in the embryo 
the ovary contains many epithelial tubules derived from 
the germinal epithelium that covers the surface of the 
ovary. These are the tubes of Pfliiger. In the process 
of development they become converted into Graafian 
follicles. Abnormally they persist, and have been 
found in the ovary at an advanced age, as late as the 
seventy-fifth year. In the newborn infant these tubes 
have been found cystic — the size of a pea. Such cystic 
degeneration of persistent tubes of Pfliiger is the probable 
origin of glandular cysts of the ovary. According to this 
view, all such cysts are due to a congenital defect. Some 
are perhaps formed congenitally, and remain stationary 
or develop in later life. 

The central cells of the tubes of Pfliiger soften and be- 
come liquefied, and the tube becomes distended into a 
small pouch lined with primitive glandular epithelium. 

The outer surface of a typical glandular cyst of the 
ovary presents a smooth, glistening, silvery appearance. 
This appearance is subject to considerable variation ac- 
cording to the character of the cyst-contents, the thick- 
ness of the wall, and the inflammatory and necrotic 
changes that have taken place. Sometimes there are 
ocher-colored or brownish spots upon the surface. 

The surface of the cyst is often lobulated, from the 
presence of smaller cysts or a collection of secondary 
cvsts in the wall. 



CYSTIC TUMORS OF THE OVARY. 355 

The wall of the cyst is composed of fibrous tissue con- 
taining elastic and unstriped muscular fibers. Traces of 
normal ovarian tissue may be discovered in the cyst- wall. 
Sometimes a corpus luteum is found in the wall of a cyst 
of large size, showing that ovarian follicles may ripen 
and rupture, and that conception may take place even 
though the ovary is grossly diseased. 

The thickest portion of the cyst-wall is that in the 
region of the pedicle. The thinnest portion is usually 
opposite the peduncular attachment. 

By careful dissection the wall may generally be divided 
into three layers — an external and an internal layer of 
fibrous structure, and a middle layer of loose connective 
tissue. This differentiation is best marked in the region 
of the pedicle. In the thinnest part of the cyst the coats 
become blended into a thin, homogeneous, fibrous struc- 
ture. 

The outer surface of the cyst is covered with a layer of 
endothelial cells. This is not a peritoneal investment. 
It is intimately connected with the outer fibrous coat of 
the cyst, and cannot be stripped off. In this respect these 
cysts differ from some hereafter to be described, in which 
there is a distinct detachable peritoneal covering. 

The blood-vessels of the tumor are distinguished 
throughout the fibrous wall. When three lamellae are 
present, the large arteries are found in the middle layer. 
Lymphatics, often of large size, are also found in the 
cyst-wall. 

The glandular cyst is always, at first, multilocular; the 
tumor is made up of several cyst-cavities. As the tumor 
increases in size the pressure causes atrophy of interven- 
ing septa, so that two or more cavities are thrown into 
one, and the number of loculi becomes correspondingly 
diminished. As the cyst grows, therefore, the tendency 
is toward the unilocular form. Careful examination of 
a unilocular glandular cyst will usually reveal the re- 
mains of atrophied septa upon the walls. 

The epithelial lining of these cysts is usually composed 



356 A TEXT-BOOK OF DISEASES OF WOMEN. 

of columnar cells. In cavities of large size the cells are 
flattened by pressure, and in cavities of the largest size 
fatty degeneration and atrophy may have taken place, so 
that the lining cells entirely disappear. 

The cavities are often lined with a soft, velvety mem- 
brane, microscopically similar to mucous membrane. 
The columnar epithelium dips below the surface to form 
complex mucous glands. These glands may become ob- 
structed, and secondary mucous retention-cysts are formed 
in the walls of the parent cyst. Such a mass of second- 
ary cysts is often seen projecting into the main cyst-cav- 
ity or forming a lobulated prominence upon its outer 
surface. 

Follicular cystic degeneration, such as has already been 
described, may occur in the ovarian tissue of the wall of 
the glandular cyst, so that a secondary group of small 
cystic cavities may be formed. 

It is thus seen that the structure of an oophoritic 
glandular cyst may be very complex. There may be one 
or more chief cyst-cavities, on the walls of which may be 
discovered the remains of septa which had formerly sub- 
divided them. Projecting into the cavities may be seen 
honeycomb-like masses of secondary mucous retention- 
cysts; while in the walls of the tumor, perhaps render- 
ing the surface lobulated, may be seen minor cyst-cavities 
formed by beginning glandular cystic degeneration or by 
simple cystic degeneration of ovarian follicles (Fig. 167). 

The contents of a glandular cyst vary greatly, not only 
in different cysts, but in the different cavities of the 
same cyst. Pseudomucin, a peculiar mucoid substance 
excreted from the lining gland cells, is a most important 
constituent of the contents of this cyst, and is almost 
characteristic. 

The fluid may be thin and colorless; it may resemble 
thick, tenacious mucus; it may be oily or syrupy in con- 
sistency; or it may resemble transparent jelly. It may be 
colorless, yellow, apple-green, or brown or black from the 
presence of decomposed blood. As a rule, the fluid 



CYSTIC TUMORS OF THE OVARY. 



357 



becomes thinner as the cyst increases in size and age. 
The change is probably due to the alteration that takes 
place in the character of the lining membrane under the 
influence of continuously increasing pressure. 

The specific gravity of the fluid varies from ioio to 
1050. 




Fig. 167. — An oophoritic glandular cyst. The section shows the remains of 
an atrophied septum, a number of follicular cysts in the wall, and to the right 
a group of mucous retention-cysts. 



As glandular cysts of the ovary originate in the free 
border of the gland, they are in the great majority of 
cases intra-peritoneal in their growth. They grow into 
the peritoneal or the abdominal cavity; they do not push 
aside layers of peritoneum, like the cysts that originate 
between the folds of the broad ligament, and which are 
extra-peritoneal in their development. 



358 A TEXT-BOOK OF DISEASES OF WOMEN. 

Very rarely glandular cysts of the ovary have been 
found that grew between the layers of the broad ligament 
and were extra-peritoneal in development. It may be 
that in such cases the ovary itself had occupied an ab- 
normal position. 

The shape of the ovary is very early destroyed by a 
glandular cyst. The ovarian tissue is incorporated with, 
and is spread throughout the cyst-wall. In small tumors 
the remains of the hilum may be found at the pedicle. 
In no case is the body of the ovary discoverable as a 
distinct structure lying upon the surface of the cyst. 

The pedicle of the cyst is composed of the ovarian lig- 
ament, the upper portion of the broad ligament, and the 
Fallopian tube. These structures are all more or less 
thickened and lengthened as a result of the traction and 
of the altered nutrition produced by the growing cyst. 

The vessels of the pedicle that are derived from the 
ovarian and uterine arteries are of various size. The 
arteries rarely exceed the size of the radial artery. 

Glandular cysts are of unlimited growth. They in- 
crease in size until they destroy the woman by direct 
pressure. They literally crowd her out of existence. 

The size they may attain is determined only by the 
powers of resistance of the woman and the distensibility 
of the abdominal walls. Glandular cysts have been re- 
moved that weighed 200 pounds. 

The shape of the glandular cyst is approximately 
spherical. If is often distorted by pressure, and portions 
of the tumor may represent a mould of parts of the pel- 
vic or posterior abdominal walls. 

The glandular cyst is usually unilateral. The propor- 
tion of cases in which both ovaries are affected seems to 
be about 4 per cent. 

In some cases, when both ovaries are affected, the cysts 
may become fused, so that a single tumor is formed, at- 
tached by two distinct pedicles. Operation in such cases 
is often very embarrassing. 

The glandular cyst is the most common form of ovarian 



CYSTIC TUMORS OF THE OVARY. 359 

tumor. It may occur at any time of life from childhood 
to old age. It is most common between the ages of 
twenty and fifty. 

Dermoid Cysts. — A dermoid cyst of the ovary is cha- 
racterized by the presence of skin and cutaneous appen- 
dages. Dermoid cysts are found in various parts of the 
body, but they occur most frequently in the ovary. Of 
188 dermoid cysts reported by Lebert, 129 occurred in 
the ovary. 

Dermoid cysts comprise from 4 to 5 per cent, of all 
ovarian tumors. 

Simple ovarian dermoids are usually of small or mod- 
erate size, varying from the size of a hen's egg to that of 
the adult head. The cysts rarely contain more than 8 
pints of fluid. 

Dermoid cysts may become larger by fusion with gland- 
ular cysts or as the result of inflammation. Dermoid cysts 
are usually unilateral; both ovaries are affected in about 
20 per cent, of the cases. They are primarily unilocular. 
Sometimes two or more dermoid cysts spring from the 
same ovary, and these contemporaneous cysts may be- 
come united, and the contiguous walls may atrophy so 
that the cavities communicate. 

Dermoid cysts of the ovary have been found at all ages 
— in the fetus of eight months and in women over eighty 
years of age. They are observed most frequently from 
the fifteenth to the forty-fifth year. 

The external appearance of the dermoid cyst differs 
from that of the glandular cyst. It is dull and often 
yellowish or brownish in color. 

Upon the internal surface of the cyst is found a mem- 
brane which looks like skin and which has a similar 
structure. The skin may cover the whole of the surface 
of the cavity, or it may be restricted to a small area, and 
with the underlying tissue form a prominence of the cyst 
wall — the so-called parenchyma body. This body is com- 
posed of tissue derivatives of one, two, or all three layers 



360 A TEXT-BOOK OF DISEASES OF WOMEN. 

of the blastoderm from the surface inward — the ectoderm , 
mesoderm, and entoderm. 

The following cutaneous appendages are found: hair, 
sebaceous glands, sweat-glands, teeth, mammae, horn, 
nails. The cyst may also contain bone, unstriped mus- 
cle, and tissue resembling brain-matter. 

The hair may arise from the whole surface of the cyst, 
or tufts of various length may be found growing from 
slight prominences of the surface. The hair is usually 
short; it is sometimes found, however, varying in length 
from 4 or 5 inches to 5 feet. 

There seems to be no relation between the color of the 
hair of the dermoid and that upon the external surface 
of the body of the individual. The hair in an ovarian 
dermoid of a negress has been found of a blonde color. 

The hair changes in color with age, and in an old 
woman may become white. 

The hair is constantly shed, and the cyst may contain 
a large quantity of short loose hair mixed with the other 
contents. Sometimes the shed hair is found rolled up in 
balls of sebaceous matter. 

Sebaceous glands and sweat-glands are usually nu- 
merous. 

Teeth may be found free in the cyst-cavity, or they 
may be attached to bone or cartilage within the cyst- wall, 
while the crowns project into the cavity; or they may lie 
completely imbedded in the wall. They are often well 
formed, though they may be faulty in development and 
shape. They are usually few in number, ranging from 
one to ten. Many more teeth than this, however, are 
sometimes found; in one case there were 300. 

Mammae are found in various degrees of development. 
In some cases there are present one or more tags of skin 
resembling a nipple. In others the mammae may be well 
formed and may contain glandular tissue. 

The bones appear as delicate laminae or spiculae in the 
cyst-wall. They often present a striking resemblance 
to the flat bones of the skull and the jaw-bones. 



CYSTIC TUMORS OF THE OVARY. 361 

The contents of a dermoid cyst vary in consistency. 
All the substances discharged from the lining membrane 
enter into their composition. They may consist of a 
thick oily fluid of a yellowish or brown color, or a pulta- 
ceous, semi-solid mass. They resemble the contents of 
a wen or a sebaceous cyst. They are usually filled with 
loose hairs and exfoliated epithelium. Though the fatty 
contents may be in a fluid condition during life, yet they 
solidify when exposed to the air and after death. 

In some cases a dermoid cyst has been found in one 
ovary while a glandular cyst was in the other. Again, a 
single ovary may be the seat of a mixed tumor composed 
of dermoid and glandular cysts. In most of such cases 
the dermoid forms a single loculus of the tumor. Some- 
times the septum between the dermoid cavity and the 
glandular cystic cavity atrophies and the two cavities 
are thrown into one. Such an occurrence explains those 
cases in which the cavity of a multilocular cyst is found to 
be partly lined with skin which is continuous with the 
cylindrical epithelium characteristic of the glandular 
cyst. 

The sebaceous glands and the sweat-glands in the walls 
of an ovarian dermoid may become obstructed and 
undergo cystic degeneration, forming in this way groups 
of secondary cysts. 

Dermoid cysts of the ovary are usually intra-peritoneal 
in their growth, like the glandular cysts. In some cases, 
however, they develop between the layers of the broad 
ligament, and may assume any of the positions charac- 
teristic of such extra-peritoneal growths. 

Teratoma, a very rare form of ovarian tumor, is an 
atypical modification of the dermoid, the teratoma bear- 
ing a relation to the dermoid similar to that of carcinoma 
to adenoma. While in the dermoid the chief mass of the 
tumor has a cystic character, the cystic cavity containing 
the secretions from the lining epidermal tissue, the tera- 
toma is for the most part a solid tumor, and the produc- 
tive activity of the tissue is a cellular hyperplasia. 



362 A TEXT-BOOK OF DISEASES OF WOMEN. 

They appear as pedunculated nodular tumors, with a 
smooth surface, usually reaching a large or enormous size. 
The substance of the tumor is composed of the dermoid 
tissue spoken of, formed into irregular masses of various 
size, form, color, and consistency, separated by connec- 
tive-tissue fascicular and infiltrated with small and minute 
cysts (^dilated glands or degenerated areas). The tumor 
is characterized by an atypical arrangement, form, and 
structure of the epithelium (after the type of a carci- 
noma) and an excessive growth of embryonal connective 
tissue (after the type of a sarcoma). It is extremely ma- 
lignant, being destructive and distributed by metastasis 
and implantation. 

The cause of dermoid tumors of the ovary is unknown. 
Several different theories have been advanced, no one of 
which seems to be generally acceptable. 

PAROOPHORITIC CYSTS, OR PAPILLOMATOUS OVARIAN 

CYSTS. 

There is an interesting variety of ovarian cysts which 
is characterized by the presence of papillomata, or warts, 
upon the inner surface. These cysts arise from the paro- 
ophoron or from the hilum of the ovary. Many theories 
have been advanced to explain the origin of these tumors. 
Pathologists are far from agreeing upon this subject. 
Perhaps the most popular view among English and 
American pathologists is that the papillomatous cysts 
originate from the remains of the Wolffian body which 
may persist in the paroophoron in various stages of de- 
generation. 

As paroophoritic cysts spring from the hilum or the 
attached portion of the ovary, and develop in the direc- 
tion of least resistance, they very often separate the 
lamellar of the mesovarium and invade the loose connec- 
tive tissue between the layers of the broad ligament. 
These cysts are thus very often extra-peritoneal or intra- 
ligamentous in their development. 



CYSTIC TUMORS OF THE OVARY. 



363 



Some writers of experience state that three-fourths of 
all papillomatous tumors of the ovary are of intra-liga- 
mentous growth. This has not been the experience of 
the author. The majority of the papillomatous ovarian 
cysts that he has seen have been intra-peritoneal in de- 
velopment, and have had as well-defined pedicles as the 
ordinary multilocular ovarian cyst. 




Fig. 168. — Papillomatous cyst of the paroophoron. The section shows the 
papillomatous growths in the interior and the relation of the oophoron. 

Cyst-wall. — If the papillomatous cyst be intra-peri- 
toneal in development, two layers of tissue may be dis- 
tinguished in its wall: an outer dense layer, composed 
of laminated connective tissue which sometimes contains 
unstriped muscle-fibers; and an inner loose layer of 
fibrous tissue. Both layers contain numerous blood- 
vessels. 

If the cyst be extra-peritoiieal or intra-ligamentous in 



364 A TEXT-BOOK OF DISEASES OF WOMEN. 

its development, we find, in addition to the two layers just 
described, an outer coat of peritoneum which is derived 
from the broad ligament. 

The internal surface of the cyst — the walls and the 
papillae — is covered by a single layer of cylindrical epi- 
thelial cells, which may become flattened by pressure in 
the large cysts. The epithelium is often ciliated. 

Upon the interior of the papillomatous cyst are found 
warts or papillary growths. These growths vary in size 
from that of a grain of sand to that of the fetal head. 
They may be scattered over the cyst- wall or collected in 
groups. The larger growths often form arborescent, 
cauliflower-like masses, which may be so numerous and 
luxuriant that rupture of the cyst results. 

In color the papillomata vary from whitish to dark 
red or black, according to the vascular supply. They 
are sometimes yellow as the result of fatty degeneration. 
They are usually very vascular, and bleed freely when 
manipulated. 

The papillomata may be sessile or pedunculated. The 
pedicle is sometimes very long and thin. Calcification 
of the papillomata often takes place. 

Papillary cysts are usually unilocular. In any case the 
number of secondary loculi is much smaller than in the 
glandular cyst. 

Fluid Contents. — The fluid contents of the papilloma- 
tous cyst differ considerably from those of the glandular 
cyst of the ovary. 

In the papillomatous tumor the contents are usually 
clear and of a watery consistency, with a specific gravity 
of from 1005 to 1040. They are not often thick, mucous, 
or gelatinous in consistency, as in the glandular cyst. 
The color varies from light yellow to dark brown from 
admixture of blood. As in all cystic tumors, the cha- 
racter of the contents depends upon the accidents that 
have happened during the growth of the cyst. 

Papillomatous cysts are more often bilateral than any 



CYSTIC TUMORS OF THE OVARY. 365 

other cystic tumors of the ovary. They affect both ova- 
ries in from 50 to 75 per cent, of the cases. For this 
reason the operator should always carefully examine the 
second ovary after removing an ovarian cyst, for begin- 
ning cystic degeneration may be found in it also. 

Papillary cysts are usually of smaller size and of slower 
growth than glandular cysts. The papillomata usually 
perforate the cyst and invade the peritoneum before large 
size has been attained. These tumors, therefore, are not 
often seen of larger size than the adult head. 

Though papillomatous cysts of the ovary are not as 
common as the glandular cystomata, yet they are by no 
means unusual. The statistics of operators vary a great 
deal. In 600 ovariotomies Schroeder found 50 papillom- 
atous cysts — somewhat over 8 per cent. In the ex- 
perience of the writer they have been very much more 
frequent than this. 

The papillomatous cyst is the most dangerous cyst 
affecting the ovary. The danger lies in metastasis of the 
papillomatous growths to the general peritoneum. Meta- 
stasis occurs from the perforation of the cyst- wall and 
the escape into the peritoneum of the papillomatous 
masses. 

The tendency to rupture of the cyst- wall is one of the 
characteristics of this form of tumor. The wall becomes 
weakened by atrophy or fatty degeneration, or by direct 
pressure of the luxuriant papillary growths. These 
growths make their way to the outer surface of the cyst, 
and extend thence throughout the peritoneum; or, if rup- 
ture takes place, the cyst may become so inverted that the 
site of each ovary is occupied by a mass of papillomata; 
the formerly enclosing cyst has disappeared, and its re- 
mains can be discovered only by careful dissection (Fig. 
169). Such a condition has undoubtedly often been mis- 
taken for primary papilloma of the ovary, the real origin 
in a papillomatous cyst not having been detected. 

The secondary affection of the peritoneum is due not 
only to continuity of tissue, but to implantation and 



366 A TEXT-BOOK OF DISEASES OF WOMEN. 

growth of portions of papillomata that have become 
broken off and carried to different parts of the peritoneal 
cavity. Such secondary growths may extend through- 
out the whole abdomen from the pelvis to the diaphragm, 
covering any of the viscera. They resemble in all re- 
spects the original papillomata found in the interior of 
the ovarian cyst. They sometimes form cauliflower-like 
masses as large as the fist, and may be palpated through 
the abdominal wall. They are very vascular, and bleed 
profusely on being handled. The smallest particles of 




Fig. 169. — Double papillomatous cyst of the ovary. The right cyst has rup- 
tured and is turned inside out, showing a mass of papillomata. Papillomata 
have penetrated the wall of the left cyst. The peritoneum has been infected, 
and a papillomatous growth appears on the fundus uteri. 

papillomata are capable of infecting the peritoneum or 
other tissues in this way. 

The escape of a small quantity of the cyst-fluid into 
the abdomen during the removal of the tumor may cause 
subsequent recurrence in the peritoneum. Secondary 
development of the growth in the abdominal cicatrix, or 
its appearance in the site of puncture after tapping, is 
due to the same cause. 

Papillomata of the peritoneum are usually accompanied 
by ascites. This is a prominent symptom in those cases 
of papillomatous ovarian cyst in which secondary infec- 
tion of the peritoneum has taken place. In rare cases. 



CYSTIC TUMORS OF THE OVARY. 367 

ascites is present, though perforation of the cyst and in- 
volvement of the peritoneum cannot be detected. 

Sometimes perforation of the cyst takes place into ad- 
jacent organs, especially if the growth be intraligament- 
ous. In such cases the papillomatous masses may pro- 
trude into the bladder, the rectum, or the cavity of the 
uterus. 



CHAPTER XXX. 
CYSTS OF THE PAROVARIUM. 

The parovarium consists of a series of fine tubules 
lying between the layers of the mesosalpinx. It may be 
seen in the fresh specimen by holding the mesosalpinx 
stretched between the eye and the light (Fig. 145). 

The typical parovarium consists of three parts: a series 
of vertical tubules; a series of outer tubules free at one 
extremity; and a larger longitudinal tubule. 

The vertical tubules range from five to twenty-four in 
number. They converge somewhat toward the ovary, 
where they end in blind extremities and become closely 
associated with the paroophoron. At the other end they 
terminate in the larger longitudinal tubule. 

The series of outer tubules are called Kobelt's tubes. 
They are free and closed at the distal extremity, while at 
the proximal extremity they join the longitudinal tubule. 
The larger longitudinal tubule is called the duct of 
Gartner. It may sometimes be traced traversing the 
broad ligament to the uterus, and through the walls 
of this organ and of the vagina to its termination at the 
urethra. It corresponds to the vas deferens in the male. 
When persistent in the vaginal wall it may become the 
starting-point of a vaginal cyst. 

The vertical tubes of the parovarium are from 0.3 to 
0.5 millimeters in diameter. They are occasionally found 
lined with ciliated columnar epithelium. Usually they 
contain a granular detritus representing the remains of 
broken-down epithelium. 

Cysts may arise from any of the parts of the paro- 
varium. 

Kobelt's tubes frequently become distended, and form 

368 



CYSTS OF THE PARO VARIUM. 



3 6 9 



small pedunculated cysts about the size of a pea. They 
are of no clinical importance (Fig. 145). They are often 
observed in operations for ovarian disease, and are very 
often mistaken for the hydatid or the cyst of Morgagni 
which springs from the Fallopian tube, and which has 
already been described. 

The difference between these two varieties of small 




Fig. 170.' — Cyst of the parovarium. There is no distortion of the ovaiy. 
Fallopian tube has been much elongated. 



The 



cysts may be determined by careful examination of the 
point of origin and by means of the microscope. Sutton 
states that the cyst of Morgagni has muscular walls and 
is lined by ciliated columnar epithelium. In the cyst of 
Kobelt's tubes the walls are fibrous and the liniiiQ: is 
cubical epithelium. 

Large cysts of the parovarium originate from the verti- 

24 



37o A TEXT-BOOK OF DISEASES OF WOMEN. 

cal or the longitudinal tubules, and usually remain ses- 
sile and develop between the layers of the mesosalpinx 
and the broad ligament. As the cyst grows and separates 
the layers of the mesosalpinx, it comes into close rela- 
tionship with the Fallopian tube. This structure, being 
held by its uterine connection and the tubo-ovarian liga- 
ment, becomes stretched across the surface of the cyst 
and very much elongated. The elongation of the Fallo- 
pian tube is a very constant accompaniment of parova- 
rian cysts. The tube may attain a length of 15 or 20 
inches. The fimbriae may also become much stretched 
and elongated by the traction of the growing cyst, and 
may attain a length of 4 inches. 

The ovary is unaffected unless the cyst be of very large 
size, in which case the ovary may be stretched upon the 
surface of the cyst, so that its position becomes difficult 
to determine. 

There are' two varieties of parovarian cyst — the simple 
and the papillomatous. 

The simple parovarian cyst has a very thin wall of uni- 
form thickness. In small cysts, less than the size of a 
child's head, the wall may be transparent. It is of a 
light yellowish or greenish color, and the fine vessels 
ramifying upon the surface are plainly visible. As one 
would expect from the direction of growth, the outer cov- 
ering of the cyst is peritoneum, which is not adherent 
and may be readily stripped off. The middle coat is 
composed of fibrous tissue containing unstriped muscle. 
The lining membrane is ciliated columnar epithelium, 
stratified epithelium, or simple fibrous tissue, according 
to the size of the cyst. The changes in the character of 
the epithelium are due to pressure. The cyst-contents 
are a clear, limpid, opalescent fluid of a specific gravity 
below 1010. 

In the papillomatous parovarian cyst the interior is 
covered with warts or papillomatous growths resembling 
in every respect those that occur in the cyst of the paro- 
ophoron, already described. The papillomatous parova- 



CYSTS OF THE PAROVARIUM. 371 

rian cyst exhibits the same clinical features, and is liable 
to the same accidents, as the paroophoritic cyst. It may 
become perforated and infect the general peritoneum. 

The walls of the papillomatous parovarian cyst are some- 
what thicker than those of the simple parovarian cyst; the 
fluid contents are not so clear and limpid, and may con- 
tain altered blood that has escaped from the papillomata. 

Parovarian cysts are almost invariably unilocular. 
Only a few cases have been reported in which two or 
more cavities were present. 

The cysts are of small size, not often exceeding that 
of a child's head. They may, however, attain large di- 
mensions and contain several quarts of fluid. 

Parovarian cysts are of very slow growth, and refill 
but slowly after tapping or rupture. On account of the 
thinness of the cyst-walls, these cysts seem especially 
liable to the accident of rupture. Unless the cyst be 
papillomatous, the bland, unirritating fluid is readily ab- 
sorbed by the peritoneum, and the cyst may remain qui- 
escent for a long period. 

Cysts of the parovarium occur most frequently during 
the period of active sexual life. Unlike dermoids and 
cysts of the oophoron, they are unknown in childhood. 

Cysts of the parovarium are much less common than 
cysts of the oophoron and paroophoron. In 284 tumors 
of the ovary and parovarium operated upon by Olshausen, 
about 11 per cent, originated in the parovarium. 

Some authorities maintain -that in rare instances der- 
moid cysts may arise from the parovarium. 

The symptoms of parovarian cysts resemble those of 
ovarian cysts of similar development. On account of the 
intra-ligamentous development of the tumor, pressure- 
symptoms may appear early. The cyst is of such slow 
growth that the simple parovarian cyst may exist for a 
long time without giving any trouble whatever. The 
slow growth is the only clinical feature that would enable 
one to make a diagnosis between parovarian and ovarian 
cvst. 



372 A TEXT-BOOK OF DISEASES OF WOMEN. 



COMPARISON OF OOPHORITIC, PAROOPHORITIC, 
PAROVARIAN CYSTS. 



AND 



The chief characteristic features of the large cysts of 
the ovary and the parovarium — the glandular cyst, the 





Fig. 171. — Section, perpen- 
dicular to the long axis of the 
Fallopian tube, passing through 
the tube, the parovarium, and the 
ovary; showing the relation of 
the structures to the peritoneum 
of the broad ligament. 



Fig. 172. — Section, perpendicular to 
the long axis of the Fallopian tube, 
showing the relation of an oophoritic 
cyst to the peritoneum of the broad lig- 
ament. 



paroophoritic cyst, and the parovarian cyst — may be tabu- 
lated for comparison as follows: 




Fig. 173. — Section, perpendicular to the long axis of the Fallopian tube, 
showing the relation of a paroophoritic cyst to the oophoron and the peritoneum 
of the broad ligament. 



Glandular Oophoritic Cyst. — Intra-peritoneal in de- 



CYSTS OF THE PAROVARIUM. 



373 



velopment; no peritoneal investment. Ovary destroyed 
early in the course of the disease. Cyst multilocular. 

Fluid contents thick, colored; specific gravity greater 
than ioio. 

Tumor of rapid growth. 

Usually unilateral. 

Fallopian tube distinct from tumor, and not much, if 
any, elongated. 

Paroophoritic Cyst. — Often extra-peritoneal in de- 
velopment, in which case there is a detachable peri- 
toneal investment. 

Oophoron not at first involved by the growth. 

Unilocular. 

Fluid contents less thick and viscid than in oophoritic 
cyst. 

Interior filled with papillomata. 

Tumor usually of slower 
growth than the oophoritic 
cyst. 

Very often bilateral. 

Fallopian tube more likely 
to be involved than in oopho- 
ritic cyst. 

Cysts of the Parovarium. 
— Intra-ligamentous in de- 
velopment. Peritoneal invest- 
ment which may be stripped off. 

Ovary pushed aside, but 
shape not affected unless the 
cyst be very large. 

Cyst unilocular. 

Wall thin. Fluid contents watery, opalescent; spe 
cific gravity below ioio. 

May or may not have papillomata in interior. 

Tumor of very slow growth. 

Usually unilateral. 

Fallopian tube much elongated and stretched iininedi 
ately over the surface of the cyst. 




Fig. 174. — Section, perpendicu- 
lar to the long axis of the Fallo- 
pian tube, showing the relation of 
a parovarian cyst to the ovary, the 
tube, and the peritoneum of the 
broad ligament. 



CHAPTER XXXI. 

NATURAL HISTORY AND TREATMENT OF OVARIAN 

CYSTS. 

In the discussion of the secondary changes, the clin- 
ical history, and the treatment of cysts, the oophoritic, 
paroophoritic, and parovarian cysts will be considered 
together under the general heading of ovarian cysts. 

SECONDARY CHANGES OR ACCIDENTS OF OVARIAN 
CYSTS. 

There are various accidents which may happen to an 
ovarian cyst which have an important bearing on the 
clinical course of the disease. These accidents are: in- 
flammation and suppuration; torsion of the pedicle; rup- 
ture of the cyst. 

Inflammation and Suppuration. — Inflammation of 
an ovarian cyst is of very common occurrence. It seems 
especially liable to happen in the small cysts of pelvic 
growth. Ovarian dermoids are very often inflamed. The 
inflammation may result in but a few peritoneal adhesions 
between the outer surface of the cyst and some of the 
contiguous structures, as a loop of intestine, the bladder, 
the anterior abdominal wall, the omentum, etc., or the 
whole cyst may be universally adherent, so that its re- 
moval is rendered most difficult, and in some cases im- 
possible. 

The operator should always remember the possibility 
of these adhesions in removing an ovarian cyst. Its sur- 
face should be carefully examined as it is dragged slowly 
through the abdominal incision, in order that slight 
adhesions to delicate structures like the omentum and 
the vermiform appendix may not be recklessly or un- 
knowingly torn. 

374 



NA TURAL HISTOR Y OF VARIAN CYSTS. 375 

The sources of inflammatory infection of an ovarian 
cyst are the intestinal tract, the urinary bladder, and the 
Fallopian tube. Perhaps salpingitis is the most frequent 
cause of such inflammation. Infection often comes from 
the vermiform appendix, which is frequently found ad- 
herent to the surface of the tumor. 

Old adhesions usually contain blood-vessels, which may 
be of large size, especially if they arise from the intestine, 
the omentum, or the uterus. In some cases in which tlie 
tumor has become detached from the pedicle by rotation 
or traction the adhesions have been sufficiently vascular 
to maintain the vitality of the tumor. 

Suppuration of ovarian cysts is sometimes seen. It 
was more frequent in the period when these tumors were 
treated by tapping, as infection occurred in this way. 

Suppuration is most common in ovarian dermoids. 
The tumor may become adherent to surrounding struc- 
tures, and may discharge its contents through the bladder, 
the vagina, the rectum, or the abdominal wall. A tooth 
thus discharged into the bladder from a suppurating der- 
moid has in several instances formed the nucleus of a 
vesical calculus. 

A suppurating ovarian cyst sometimes contains gas, 
either from communication with the intestine or from 
decomposition of its contents. In such a case the usual 
tumor-dulness is replaced by a tympanitic note. 

Torsion of the Pedicle, or Axial Rotation.— Ova- 
rian tumors occasionally rotate upon their axes, so that 
the structures that form the pedicle become twisted. The 
severity of the symptoms that arise from this accident 
depends upon the degree of compression to which the 
vessels of the pedicle are subjected from the torsion. 

The accident is not now as common as formerly, be- 
cause the tumor is, as a rule, now removed as soon as it 
is recognized, and many of the accidents that were de- 
scribed as very frequent by the older writers are avoided. 
The many recorded cases — chiefly of a date before our 
present surgical era — show that axial rotation occurred in 



376 A TEXT-BOOK OF DISEASES OF WOMEN. 

about 10 per cent, of the cases of ovarian and parovarian 
tumors. Rokitansky found torsion of the pedicle in 12 
per cent, of all cases of ovarian tumors, and in 6 per cent, 
of the cases it was the cause of death. 

The cause of axial rotation is unknown. It has been 
attributed to alternate distention and evacuation of the 
bladder, to the passage of feces through the rectum, and 
to a sudden jar or motion of the body. 

The accident is especially likely to occur when an 
ovarian cyst complicates pregnancy or when both ovaries 
are cystic. Torsion of both pedicles has been found in 
women suffering with bilateral ovarian cysts. 

Torsion of the pedicle is more apt to occur in cysts of 
medium and small size than in the large tumors. 

Torsion of the pedicle affects equally tumors of the 
right and left sides. The direction of rotation is usually 
toward the median line, though it may take place in the 
reverse direction. 

There is considerable variation in the amount of rota- 
tion. In some cases the pedicle has twisted through but 
half a circle, while in others twelve complete twists have 
been found. A pedicle twisted in this way resembles a 
rope. Such a high degree of torsion is the result of a 
slow or chronic process. The rotation of the tumor takes 
place so gradually, or the arrangement of the blood-ves- 
sels in the pedicle is such, that no appreciable effect upon 
the tumor is produced, and no symptoms arise from it. 
The operator frequently meets examples of such slow 
torsion in removing ovarian tumors. In extreme cases 
the twisting progresses until the blood-supply through 
the pedicle is arrested, and the cyst may become freed 
from its peduncular attachment. If adhesions had formed 
to the cyst-wall, the vitality may be maintained through 
these channels; the tumor, in fact, becomes transplanted. 
This phenomenon is most frequent with dermoids. 

Very different are the phenomena of acute torsion. 
Here the vascular supply of the tumor is so suddenly 
and markedly interfered with that most urgent symptoms 



NA TURAL HISTOR Y OF O VARIAN CYSTS. 377 

immediately arise. The interference with the circula- 
tion depends upon the amount of the twist and the cha- 
racter of the pedicle. The effect is first felt by the veins, 
which are more compressible than the arteries; the ven- 
ous blood-current becomes obstructed, while the arteries 
remain open. Venous engorgement of the cyst results; 
extravasation of blood takes place in the walls, or the 
veins may rupture and hemorrhage may take place into 
the cyst-cavity. Death from acute anemia may result 
from this cause. Thrombosis and necrosis of the tumor 
may occur as a result of acute torsion. 

Rupture of Ovarian Cysts. — Rupture of an ovarian 
cyst is an accident of not infrequent occurrence. It is 
probable that small cysts rupture and refill without the 
attention of the woman or the physician being directed to 
the accident. The scars of old ruptures are frequently 
found on the surface of ovarian cysts. Wells found rup- 
ture of the cyst 24 times in a series of 300 ovariotomies. 

There are various causes which predispose to rupture 
or lead to it. As the cyst enlarges, the walls become 
very thin as a result of the distention. The cyst-wall 
may undergo, in places, retrograde changes — atrophy and 
fatty degeneration. The wall may become weakened as 
a result of suppuration, thrombosis, and the results of 
torsion of the pedicle; and, as has already been said, pap- 
illomatous growths destroy the integrity of the wall and 
lead to perforation. 

The immediate cause of the rupture is usually a sud- 
den jar or a fall. Sometimes very slight pressure is 
enough to rupture the cyst. The manipulations of a 
physician, turning in bed, and coughing have caused this 
accident. 

The effects of rupture depend upon the character of 
the cyst-contents. 

Hemorrhage may be profuse and rarely fatal. The 
hemorrhage, however, is usually not severe, because the 
rupture takes place in the attenuated part of the cyst, 
which is but poorly supplied with blood-vessels. 



378 A TEXT-BOOK OF DISEASES OF WOMEN. 

If the fluid is unirritating to the peritoneum and con- 
tains but little solid material, it is often readily absorbed 
by the peritoneum and passed off by the kidneys. Large 
quantities of fluid may be absorbed and eliminated in this 
way. A case has been reported in which the rupture 
of a cyst was followed by profuse diuresis which lasted 
four days, during which time 65 pints of urine were dis- 
charged. 

Another case has been reported in which the cyst rup- 
tured and refilled 34 times during a period of nine years. 
The fluid on each occasion was absorbed by the perito- 
neum and discharged by the kidneys without in any way 
incapacitating the woman. 

If the cyst-contents are septic, as is often the case in 
dermoid cysts, fatal peritonitis will result. The danger 
of rupture of the papillomatous tumors — general papil- 
lomatous infection of the peritoneum — has already been 
described. 

Similar infection may rarely occur from the escape into 
the peritoneum of the colloid contents of a ruptured 
glandular cyst. After such an accident the peritoneum 
has been found covered with tough gelatinous masses, of 
a gray or yellow color, which reached the size of a hick- 
ory-nut. This condition has been called myxoma peri- 
tonei. 

Very rare cases of similar metastasis from rupture of 
dermoid cysts have been reported. In one case yellow 
nodules the size of a pea, containing light-colored hair, 
were found scattered upon the peritoneum. 

It is probable that when the walls of an ovarian cyst 
are very thin, slow transudation of the fluid into the 
peritoneum takes place. 

THE CLINICAL HISTORY OF OVARIAN CYSTS. 

The symptoms produced by ovarian cysts depend upon 
their size, their position, and the accidents that may arise. 
If the tumor be intra-peritoneal in its development, the 
woman's attention is usually first directed to the patho- 



NA TURAL HISTOR Y OF O VARIAN CYSTS. 379 

logical condition when the growth has attained sufficient 
size to extend above the pelvis. The time of the percep- 
tion of the tumor depends upon the intelligence and 
powers of observation of the woman and the thickness 
-of the abdominal wall. A cyst often attains a large size 
and reaches well up into the abdomen before the woman 
is aware of its existence. In the papillomatous cysts 
sometimes the first symptoms that attract the woman's 
attention appear after the cyst has become perforated and 
the peritoneum has become invaded by the papillomata. 

Pain, except that due to pressure or inflammation or 
some other accident, is not at all characteristic of ovarian 
cysts. 

If the cyst be intra-ligamentous in development, or if 
it be wedged in the pelvis, the first symptoms of the dis- 
ease appear at an earlier date. The intra-ligamentous 
tumors first separate the layers of the broad ligament; 
they push the uterus to one side, and press upon the 
bladder, ureters, and rectum. The disposition of the 
peritoneum may be altered in a variety of ways by these 
growths. They may grow altogether behind this mem- 
brane, becoming retro-peritoneal, coming into immediate 
relationship with the rectum; or they may pass behind 
the cecum and the ascending colon, growing between 
the layers of the mesocolon. They sometimes develop 
more especially under the anterior layer of the broad 
ligament, strip off the peritoneal covering of the bladder, 
and come into immediate relationship with the anterior 
abdominal wall; so that if laparotomy is performed, the 
operator will enter the cavity of the cyst before he has 
opened the general peritoneum. It is of the greatest im- 
portance that the surgeon should be familiar with such 
unusual ways of development of these tumors, as the ope- 
rative difficulties that are encountered are most embar- 
rassing. 

Pressure upon the ureters occurs not only in the cysts 
of intra-ligamentous growth, but also in the large-sized 
intra-peritoneal tumors. It is a frequent complication, 



380 A TEXT-BOOK OF DISEASES OF WOMEN. 

and the hydronephrosis and kidney-degeneration that 
result may be the immediate cause of death. 

Doran says that in 32 cases out of 40 autopsies on 
women with large ovarian tumors, kidney disease, prob- 
ably caused by pressure of the tumors, was present. The 
writer has found a ureter distended to an inch in diameter 
from pressure of a papillomatous cyst. The pressure of 
the tumor sometimes produces edema of the lower ex- 
tremities and of the anterior abdominal walls. 

The presence of ascites with cysts of papillomatous 
nature has already been spoken of. Though this com- 
plication is especially characteristic of these tumors, and 
usually indicates peritoneal involvement, yet it is some- 
times found with the glandular and the dermoid cysts. 
In these cases it is caused by the direct mechanical irri- 
tation of the peritoneum by the movable tumor. It ac- 
companies also freely movable solid tumors of the ovary 
and pedunculated fibroids of the uterus. 

Notwithstanding the gross disease of the ovaries, the 
functions of the uterus are in no way specifically affected 
by ovarian cysts. The uterus may be pushed to one 
side, pressed backward into the hollow of the sacrum 
or forward against the pubis, but menstruation may not 
be affected, and conception may take place even with 
tumors of very large size. 

In some cases there is menorrhagia, or continuous 
bleeding, which appears with the appearance of the cyst 
and disappears after its removal. This phenomenon may 
occur in old women who have long passed the meno- 
pause, and may excite the suspicion of coincident malig- 
nant disease of the uterus. On the other hand, men- 
struation may be diminished or arrested. 

Reflex disturbances in the breast may occur with ova- 
rian cysts, as in any form of ovarian disease. The areola 
may become pigmented, the breasts swell, and a milky 
secretion may be produced even in young girls. 

Malignant degeneration may occur in any form of ova- 
rian cyst. It seems to be most frequent in the papillom- 



NA TURAL HISTOR Y OF O VARIAN CYSTS. 381 

atous tumors, next in the dermoids, and less frequent in 
the glandular cysts. 

The rapidity of growth of ovarian cysts varies a great 
deal. The glandular tumors are of the most rapid de- 
velopment. They sometimes attain a very large size 
within a few months. The rate of accumulation of the 
fluid depends upon the intracystic pressure, and is con- 
sequently greatest immediately after rupture or tapping. 
Some remarkable cases of great rapidity of accumulation 
after tapping have been reported. In one case 90 pints 
of fluid reaccumulated in seven weeks — a rate of about 
2 pints a day. In another case 3^ pints of fluid were 
accumulated every day. 

The enormous size attained by ovarian cysts, and the 
tremendous amount of fluid drawn off from them, are 
shown by the old records of the days when tapping 
the cyst was the only treatment. A few references will 
illustrate this. In one case 1920 pints of fluid were 
drawn off by 66 tappings in a period of sixty-seven 
months. In another case 2787 pints were withdrawn by 
49 tappings. In another case 9867 pounds were with- 
drawn by 299 tappings. The fluid in these remarkable 
cases must have been of low specific gravity, containing 
but little solid matter, or the women would have sooner 
succumbed from the drain on the system. 

The misery of the women who were slowly crowded 
out of existence by these enormous tumors, or who, 
though with life prolonged by tapping, were exhausted 
by the continuous drain, was depicted in their counte- 
nances. The expression was called thefacies ovariana. 
We do not often see it at the present day. Wells de- 
scribes it thus: "The emaciation, the prominent or 
almost uncovered muscles and bones, the expression of 
anxiety and suffering, the furrowed forehead, the sunken 
eyes, the open, sharply defined nostrils, the long, com- 
pressed lips, the depressed angles of the mouth, and the 
deep wrinkles curving around these angles, form together 
a face which is strikingly characteristic." 



382 A TEXT-BOOK OF DISEASES OF WOMEN. 

The natural duration of life depends upon the charac- 
ter of the ovarian tumor. A dermoid may exist from 
childhood and give no trouble — in fact, may not be rec- 
ognized until some accident starts it into rapid develop- 
ment. Bven then it is of comparatively slow and limited 
growth, and danger from it is due to the accidents, such 
as inflammation and suppuration, to which it is especially 
liable. 

Though the papillomatous cyst is also of slow growth 
when compared with the glandular cyst, yet the danger 
here is due to peritoneal infection, which very often takes 
place before the tumor has, by its size, begun to annoy 
the woman. 

The glandular cyst, however, is of rapid, continuous, 
unlimited growth, and usually destroys the woman with- 
in a period of three years. Life has been prolonged 
for a much longer period in some cases by palliative 
treatment and tapping. On the other hand, life may at 
any time be cut short by the occurrence of some acci- 
dent, such as rupture or torsion of the pedicle. 

Symptoms of the Accidents that occur in Ovarian Cysts. 
— The symptoms of inflammation are pain and tenderness 
over the surface of the tumor. The tenderness is often 
limited to a local area which marks the position of an 
intestinal adhesion. 

When suppuration takes place, the symptoms indicative 
of the presence of pus appear — elevated temperature, rapid 
and feeble pulse, exhaustion, and emaciation. 

Symptoms of Torsion of the Pedicle. — There are no 
characteristic symptoms of slow or chronic torsion, un- 
less, perhaps, retardation of the growth of the tumor 
appears as a result of the interference with the circu- 
lation. 

The symptoms of acute torsion are, however, very 
marked. The woman is seized with sudden and violent 
pain in the abdomen, accompanied by vomiting and col- 
lapse. Sometimes the abdomen becomes rapidly increased 
in size on account of the venous engorgement of the 



NA TURAL HISTOR Y OF O VARIAN CYSTS. 383 

tumor. If a woman known to have an ovarian tumor 
is thus attacked, the diagnosis of torsion of the pedicle 
may be made. The diagnosis is rendered more probable 
if the woman is also pregnant or if she has been recently 
delivered. If the woman presents herself for the first 
time to the physician with these acute symptoms, and he 
finds by abdominal and pelvic examination that there is 
an ovarian tumor, he should suspect that torsion of the 
pedicle has occurred. 

Rupture of the Cyst. — Rupture of an ovariau cyst usu- 
ally follows a fall, a violent attack of coughing, vomiting, 
etc. 

The woman is seized with sudden pain in the abdomen, 
with perhaps symptoms of collapse and loss of blood. 

The shape of the abdomen becomes quickly altered 
from that characteristic of encysted fluid to that charac- 
teristic of free fluid in the peritoneum. The alteration 
in shape is so marked that it may readily be perceived by 
the patient. 

These phenomena are followed by profuse diuresis, or 
perhaps by symptoms of peritoneal inflammation. 

If the woman survive, there is a gradual reaccumulation 
of fluid and a return of the abdomen to the former shape. 

Examination. — In the early stages of an ovarian cyst, 
while it is in the pelvic state of development, bimanual 
examination will reveal the condition. The tumor lies 
to the side, to the front, or behind the uterus. The ute- 
rus may be moved independently of the tumor. The 
cystic character of the growth may often be determined 
by palpation ; fluctuation may be felt between the vagi- 
nal finger and the abdominal hand. If the tumor be 
intra-peritoneal, with a pedicle, it will be found to be 
movable, and may be pushed out of the pelvis up into 
the lower abdomen. If it be intra-ligamentous, the range 
of motion is limited, the tumor is situated lower in the 
pelvis, and is in closer relationship with the uterus. 

The shape of the tumor is usually spherical. In a 
multilocular cyst the surface may be lobulatedj in a der- 



384 A TEXT-BOOK OF DISEASES OF WOMEN. 

moid cyst the pultaceous character of the contents may 
sometimes be determined by pressure with the vaginal 
finger. 

When the tumor has attained a sufficient size to have 
extended into the abdomen, much may be determined by 
careful abdominal examination. The woman should lie 
upon the back, and all constricting clothing should be 
removed. The whole abdomen should be exposed. 

The bulging or prominence caused by the cyst is usu- 
ally apparent in a thin woman. It commonly occupies 
the middle of the abdomen, but when not very large may 
lie to either side. 

Palpation reveals the smooth, spherical character of 
the growth, or the lobulated surface from the presence of 
secondary cysts. Perhaps an area of marked tenderness 
may be discovered, which often shows the seat of perito- 
neal inflammation and adhesion. In the papillomatous 
tumors that have become perforated, irregular masses of 
papillary growths may sometimes be felt through the 
abdominal walls, situated either on the surface of the 
tumor or in some other portion of the abdomen. The 
association of such masses with a cystic tumor of the 
ovary and ascites renders the diagnosis of papillary cysts 
very certain. 

If the tumor is non-adherent and of medium size, it may 
be moved from side to side or upward in the abdomen. 

Fluctuation may often be elicited by palpation, and 
is most marked in the unilocular cysts with thin con- 
tents. If the contents be thick, as in many of the gland- 
ular cysts, or if the cyst be multilocular, fluctuation may 
not be obtained. The wave of fluctuation is interfered 
with by intervening septa. 

Percussion reveals a central area of flatness which 
marks the most prominent part of the tumor. Intestinal 
resonance may be obtained above and to the sides of the 
cyst, and in some cases below it. In instances of this 
kind a central area of flatness is found surrounded by a 
ring of resonance. 



NA TURAL HISTOR Y OF O VARIAN CYSTS. 385 

This phenomenon is very different from that which 
appears if the fluid accumulation is free in the perito- 
neum. In the latter case the fluid gravitates to the flanks 
when the woman is upon her back, and the intestines 
float to the front, so that there is a central area of reso- 
nance, with dulness to the sides. In the very unusual 
cases in which gas is contained in the cyst-cavity the 
area of flatness will be replaced by an area of a tympan- 
itic note. 

If the woman sits up or lies on either side, the relation 
between the areas of flatness and resonance is unaltered 
in the case of an ovarian cyst, while, as is well known, 
if the fluid be free it will gravitate to the most depend- 
ent portion of the abdomen. 

Auscultation reveals nothing of importance in regard 
to ovarian tumors. It is of value in enabling one to make 
a differential diagnosis between an ovarian tumor and 
pregnancy. 

Vaginal examination in the case of a large tumor shows 
the character and the position of the lower portion of the 
growth, and sometimes enables the physician to deter- 
mine upon which side the tumor had started. In rup- 
tured papillomatous cysts the papillary masses may some- 
times be felt behind the uterus when they cannot be 
detected by the abdominal hand. 

The details of the natural history and pathological 
features already given will often enable the physician to 
make a differential diagnosis among the different kinds 
of ovarian cysts. Such a differential diagnosis, however, 
is of no importance whatever, as all such tumors require 
similar operative treatment. 

To discuss the subject of the differential diagnosis of 
ovarian cysts from other pelvic and abdominal tumors 
would require a consideration of all the pathological 
growths that may occur in the abdomen. About every 
form of abdominal tumor has been mistaken for ovarian 
cyst. Differential diagnosis is here also of but little im- 
portance at the present day if the examiner is able to 

25 



386 A TEXT-BOOK OF DISEASES OF WOMEN. 

exclude pregnancy, phantom tumor, and fat. Operation 
is indicated in practically all morbid growths of the ab- 
domen, with the exception of inoperable malignant dis- 
ease; no surgeon should undertake any abdominal ope- 
ration unless he is prepared to deal with any condition 
that may be found. 

The difficulty of making a differential diagnosis is well 
illustrated by many cases that have been recorded, in 
which it was impossible to determine the true nature of 
the tumor even after the abdomen had been opened. 

It is of the greatest importance to exclude pregnancy. 
Many women have been subjected to the operation of 
celiotomy because the pregnant uterus was mistaken for 
an ovarian tumor. Women themselves often intention- 
ally mislead the physician, especially if the pregnancy is 
illegitimate. They will even carry the deception so far 
as to go upon the operating table with the full knowledge 
that they have deceived the surgeon as to their condition. 

The physician should always remember the possibility 
of pregnancy in examining any form of abdominal tumor 
in women. The mistakes that have happened have usu- 
ally been the result of carelessness or ignorance on the 
part of the physician, though some of the most experi- 
enced operators have made this error. 

The separation of the uterus by bimanual examination 
as distinct from the abdominal tumor is the most valuable 
point in the differential diagnosis. 

The complication of pregnancy with an ovarian cyst 
renders the diagnosis more difficult. 

It is easier to make a differential diagnosis between an 
ovarian cyst and pregnancy than between some forms of 
uterine fibroid and pregnancy. 

Repeated examinations are often necessary. It is 
always advisable, in any case, to make two or more ex- 
aminations before subjecting the woman to operation. 
Much which was not at first apparent may be learned by 
several days of watching and repeated examination. 

Phantom tumor is a rare condition. A woman imagines 



TREA TMENT OF O VARIAN CYSTS. 387 

that she is suffering from a tumor and that her abdomen 
is increasing in size. The condition is likely to occur at 
the menopause, and there may readily be some physical 
grounds for the woman's suspicions, because there may 
be a constantly increasing accumulation of fat in the ab- 
dominal walls and the omentum. 

The diagnosis is usually easily made. Careful palpa- 
tion and percussion fail to reveal any pathological mass 
in the abdomen or any abnormal area of dulness. In 
these cases the abdomen is often rendered prominent by 
intestinal tympany. If any difficulty is experienced at 
the examination, the woman should be etherized. If a 
satisfactory diagnosis cannot be made, the case should be 
watched. Several cases have been reported, and there 
are probably many unreported, in which no tumor was 
found after the abdomen had been opened. 

A fat abdominal wall or omentum has often been mis- 
taken by the woman, and not infrequently by the physi- 
cian, for a tumor. These cases are often obscure; indeed, 
all the difficulties of examination, in case a tumor be 
present, are very much increased by the enormous de- 
posits of fat that are often present in the abdomens of 
women. 

Careful examination, sometimes with anesthesia, and, 
if necessary, prolonged watching should be practised. 
If a fold of the abdominal wall be picked up between 
the hands, it will often show how much of the abdom- 
inal enlargement is due to fat. 

TREATMENT OF OVARIAN CYSTS. 

Tapping. — At one time the universal method of treat- 
ing cystic tumors of the ovary was by tapping, or punc- 
ture through the abdominal wall. Many women were 
subjected to this proceeding a very great number of 
times, and, though not cured, were enabled to drag on a 
miserable existence until death resulted from exhaustion 
or from some accident to the cyst. In a few cases the 
cyst refilled very slowly, relief being experienced for sev- 



A TEXT-BOOK OF DISEASES OF WOMEN. 

eral years before a second tapping became necessary. In 
still fewer cases the tapping seemed to be curative, the 
tumor never reappearing after it had been evacuated. 
Such cases were so unusual that they should have no in- 
fluence whatever in determining the method of treatment. 
In the great majority of instances the cyst rapidly re- 
filled. Sometimes the fluid accumulated with such ra- 
pidity that evacuation became necessary every few days. 
Referring again to the old records, we find a case which 
was tapped 664 times in thirteen years — once in about 
seven days! 

If the cyst were multilocular, tapping furnished but 
partial relief. 

The proceeding itself was attended by serious dangers. 
Dr. Fock of Berlin in 1856 stated that 25 out of 132 
women — or 1 in 5^ — died within some hours or a few 
days after the first tapping. Another operator lost 9 out 
of 64 cases — or very nearly 1 in 7 — within twenty-four 
hours after the first tapping. The chief mortality oc- 
curred in the cases of multilocular tumors. Tapping 
the unilocular tumors was attended by much less danger. 

The sources of danger from tapping were the following: 
hemorrhage from puncture of a vessel in the cyst- wall; 
septic or other infection of the peritoneum; and inflam- 
mation or suppuration of the cyst. 

The majority of the women died in consequence of 
peritoneal infection. 

The danger arose not only from septic infection of the 
peritoneum, but from papillomatous or other infection 
from the escape into the peritoneal cavity of some of the 
cyst-contents. Reference has already been made to the 
occurrence of the papillomatous infection at the site of 
puncture in the abdominal wall. 

At the present day tapping an ovarian cyst with the 
hope of cure is never practised. 

Tapping as a palliative procedure should never be per- 
formed. The dangers that may result from the tapping 
cannot be disregarded, and no hope whatever of cure can 



TREA TMENT OF O VARIAN CYSTS. 389 

be held out to the patient. When operation is finally 
performed, it is rendered much more difficult from the 
adhesions that have resulted from previous tappings. 

Operation. — The treatment of ovarian cysts is opera- 
tive. Celiotomy should be performed and the tumor re- 
moved without delay. The dangers due to the accidents 
that may occur show the risk of waiting after a diagnosis 
has been made. When the tumor is small the operative 
complications and dangers are at a minimum. 

Even if the tumor be discovered accidentally by the 
physician, and has never given any trouble to the wom- 
an, operation for its removal should be advised. A der- 
moid that has existed for years may suddenly endanger 
the woman's life. Delay in the case of papillomatous 
tumors — and no one can determine in the early stages 
whether or not a cyst be papillomatous — is especially 
dangerous. About one-half the women upon whom I 
have operated for papillomatous cysts have come to me 
after the peritoneum had become infected. Though the 
peritoneum be extensively involved, operation is by no 
means hopeless. As in the case of tuberculosis of the 
peritoneum, so in papilloma, the opening and draining 
of the abdominal cavity may result in cure. 

Pregnancy is no contraindication to operation. In fact, 
the dangers of obstructed labor, of rupture of the cyst, 
and of torsion of the pedicle urgently call for immediate 
operation in such cases. Pregnancy usually progresses to 
full term after operation. 



CHAPTER XXXII. 
SOLID TUMORS OF THE OVARY. 

Solid tumors of the ovary are of rare occurrence. 
They are said to be found in about 5 per cent, of all the 
cases of ovarian tumors that are submitted to operation. 

The solid tumors of the ovary are fibromata, myom- 
ata, sarcomata, carcinomata, and papillomata. 

Fibromata. — Ovarian fibromata are very rare; they are 
histologically similar to fibroid tumors of other parts of 
the body. They do not form circumscribed new growths, 
but affect the whole organ, which becomes uniformly hy- 
pertrophied, preserving its general shape and anatomical 
relations. The tumor may contain, between the bundles 
of fibrous tissue, small cavities filled with fluid. The 
growth is usually intra-peritoneal and has a well-formed 
pedicle; it may, however, in exceptional cases be extra- 
peritoneal and develop between the layers of the broad 
ligament. In such a case there is difficulty in determin- 
ing whether the fibroid originated in the uterus or in the 
ovary. Ovarian fibromata are usually of small size and 
slow growth. A case has been reported in which the 
tumor weighed over 7 pounds. 

Corpora Fibrosa. — A variety of the ovarian fibromata 
are the corpora fibrosa, which are due to fibroid degenera- 
tion of the corpus luteum. They are tough, fibrous 
bodies, about the size of a pea, which are occasionally 
found upon the surface of the ovary. It is said that they 
may attain the size of a child's head. They are usually, 
however, very small, and have no clinical significance. 

Myomata. — Ovarian myomata are composed chiefly 
of unstriped muscular fiber. They are somewhat more 
frequent than the pure fibromata. The two growths may 

390 



SOLID TUMORS OF THE OVARY. 391 

be mixed, forming a fibro-myomatous tumor. The my- 
omatous tumor may attain the weight of fifteen pounds. 

Sarcomata. — The majority of solid tumors of the 
ovary are sarcomatous in character, and it seems prob- 
able that many tumors that are classed as fibroids or 
fibro-myomata are in reality ovarian sarcomata. The 
growth may be either of the spindle-cell or the round- 
cell variety. Occasionally it is an endothelioma, a form 
of sarcoma developing from the endothelial cells of the 
blood- and lymph-vessels. 

Sarcoma of the ovary differs from sarcoma in other 
parts of the body in the fact that it is very often bilateral. 
Sutton states that both ovaries are affected in about 20 
per cent, of the cases. Other observers state that ova- 
rian sarcomata are usually bilateral. 

The surface of the tumor is smooth, and the general 
form and anatomical relations of the ovary are unaltered. 
Ovarian sarcomata are usually of median size, though 
they may attain enormous proportions and fill the ab- 
dominal cavity. 

The tumor is usually of rapid growth; in one case it 
attained a weight of ten pounds within a period of six 
months. The growth is accelerated by pregnancy. As- 
cites is commonly present with ovarian sarcoma, and 
cachexia may appear rapidly. 

Ascites caused by peritoneal irritation may accom- 
pany any of the solid tumors of the ovary, as other 
kinds of freely movable abdominal tumor. It is, how- 
ever, especially characteristic of the ovarian sarcomata, 
and is a point of diagnostic importance. 

Ovarian sarcomata differ from the fibroid and the myom- 
atous tumors in rapidity of growth, involvement of both 
ovaries, and the presence of ascites. Ovarian sarcomata 
may occur at any age. They are relatively very frequent 
in children. An analysis of 60 cases of ovarian tumors 
in children collected by Sutton shows that sarcomata oc- 
curred 16 times. 

The symptoms caused by ovarian fibromata, myomata, 



392 A TEXT-BOOK OF DISEASES OF WOMEN. 

and sarcoma are those referable to pressure and peri- 
toneal irritation. These tumors, on account of their 
moderate size and great mobility, seem to be especially 
liable to torsion of the pedicle. They should be removed 
by celiotomy as soon as recognized. 

Both ovaries should always be carefully examined, for 
in sarcoma the disease is often bilateral. 

Carcinomata. — Primary cancer of the ovaries is very 
rare. Secondary infection of these organs is, however, 
of not infrequent occurrence. It is found in cases of 
cancer of the breast and of the uterus. In 29 cases of 
death from cancer of the breast, both ovaries were found 
to be involved in 3 cases. 

Primary cancer of the ovary appears as a solid or a 
cystic tumor. The solid carcinomata are diffuse infiltra- 
tions of the ovarian tissue, forming pedunculated, rarely 
intraligamentous, ovoid or globular tumors having a 
smooth or slightly irregular surface. They are either of 
the medullary or scirrhous type. The medullary form is 
of rapid growth, and may reach the size of the adult head. 
The scirrhous form is of comparatively slow growth and 
smaller size, and in consistency resembles a fibroma. 

The cystic carcinomata are similar in form to the mul- 
tilocular glandular cysts, but are smaller, rarely reaching 
a greater size than that of the adult head. They are 
adeno-carcinomata or papillary adeno-carcinomata. The 
surface of the tumor, its walls, and the septa contain to 
a greater or less extent solid nodules or plates of various 
size composed of carcinomatous tissue. The nodules 
often have a papillary character. 

Ovarian carcinoma is usually a bilateral growth. Un- 
like carcinoma in other parts of the body, it may, partic- 
ularly the medullary form, occur in childhood. It is 
usually found between the ages of thirty and sixty years. 
Ascites is commonly present in cancer of the ovaries, the 
fluid being often tinged with blood ; as the disease devel- 
ops, edema of the lower limbs and cachexia appear. 

Cancer of the ovary is an extremely malignant growth, 



SOLID TUMORS OF THE OVARY. 393 

quickly extending to surrounding structures as implan- 
tations on the peritoneum, and by metastasis to distant 
organs. In more than 75 per cent, of the cases operated 
upon the disease has returned and terminated in death 
within the first year. 

When cancer of the ovaries is secondary to cancer else- 
where than in the uterus, operation offers no prospect of 
cure. If the disease is secondary to cancer of the uterus, 
it may be possible to remove all of the affected structures. 

Ovarian Papillomata. — Superficial papillomata of the 
ovary are of very rare occurrence. In many of the cases 
in which the papillomata appear to grow from the surface 
of the ovary there had previously been a papillomatous 
cyst of paroophoritic origin, which had become perforated 
and perhaps inverted, so that, after the cyst had become 
destroyed, the growths appeared to spring from the ova- 
rian surface. Careful dissection and search for the re- 
mains of the old cyst should always be made in such 
Cases. 

In superficial papilloma of the ovary the growths are 
in all respects similar to those found in the interior of 
papillomatous cysts. They may be isolated upon the 
surface of the ovary, or they may cover it so completely 
that the ovary is hidden from view. A section, however, 
will reveal the ovary lying in the centre of the growth. 

The papillomata may be pedunculated or sessile. They 
vary in size. In some cases they form a mass larger than 
the adult fist. 

The disease is often bilateral. Secondary involvement 
of the peritoneum occurs, as in the case of papillomatous 
cyst. The course of the disease is similar to that of a 
perforated papillomatous cyst. The treatment is im- 
mediate celiotomy and removal. As in the case of 
papillomatous cysts, involvement of the peritoneum is 
no contraindication to operation. 

Tuberculosis of the Ovary. — Tuberculosis of the 
ovary is usually secondary to tuberculosis of the Fallo- 
pian tubes. In tuberculosis of the peritoneum the ovaries 



394 A TEXT-BOOK OF DISEASES OF WOMEN. 

are often found to be involved, in some cases without ac- 
companying disease of the tube. In phthisical women 
the ovaries have been found, in rare instances, to be the 
only portion of the genital apparatus in which secondary 
deposit of tubercles took place. 

Williams states that primary tuberculosis of the ovaries 
has not yet been described. 

The surface of the ovary may be covered with miliary 
tubercles, or they may be scattered through the substance 
of the gland. In other cases the ovary contains cavities 
filled with cheesy material or pus, forming a tuberculous 
abscess. 

There are no characteristic symptoms of tuberculosis 
of the ovaries. The condition is usually found at ope- 
ration or at autopsy, associated with tuberculosis of the 
peritoneum or of some other part of the genital organs, 
as the Fallopian tubes and the uterus. 

The treatment consists in oophorectomy, unless opera- 
tion is contraindicated on account of extensive involve- 
ment of other structures. 

Tumors of the Ovarian ligament. — Fibroid and 
sarcomatous tumors have occasionally been found in the 
ovarian ligament. Doran has reported a fibroid of the 
ovarian ligament that weighed 17 pounds. The writer 
has removed a sarcoma of the ovarian ligament that 
weighed 5 pounds. 

It is impossible to distinguish these tumors from similar 
growths of the ovary. They demand like treatment. 



CHAPTER XXXIII. 
MALFORMATIONS OF THE GENITAL ORGANS. 

Congenital malformations are found in all parts of 
the genital tract. Some of the more common forms, like 
arrested development of the uterus, have been referred to 
in the previous pages. Others will briefly be considered 
here. Reference to the method of development of the 
sexual organs will elucidate this subject. 

The Fallopian 'tubes, the uterus, and the vagina are 
developed from two embryonic structures called the ducts 
of Miiller. These ducts become fused, first at the lower 
extremity, between the sixth and eighth weeks of fetal 
life (Fig. 175). The early genital tract thus formed is 







Fig. 175 — Diagrams showing the development of the vagina and the uterus 
from Miiller' s ducts. 

consequently divided throughout by a septum, which 

normally disappears during fetal development, so that 

there results one vaginal and uterine tract, from which 

the Fallopian tubes branch. 

The most important malformations of the vagina and 

395 



396 A TEXT-BOOK OF DISEASES OF WOMEN. 

the uterus arise from arrest, at any stage, of this normal 
developmental process. 

Very rarely the uterus is completely absent, or it may 
be represented by a small band of muscular and connec- 
tive tissue stretched across the pelvis. In other cases the 
cervix is well formed, while the body of the uterus is but 
poorly developed. 

We have seen that this condition is often associated with 
pathological anteflexion of the uterus. 

Uterus Unicornis. — Sometimes there is arrest in the 
development of one of Miiller's ducts, so that the uterus 
becomes one-sided or one-horned and presents only one 
formed Fallopian tube. In such a case both ovaries may 
be present. 

Uterus Didelphys. — Miiller's ducts may unite only as 
far as the top of the vagina, no fusion whatever taking 
place in the uterine portion. In such a case two sepa- 




Fig. 176. — Uterus didelphys and double vagina. 



rated uterine bodies are produced; the condition of double 
uterus exists (Fig. 176). 

Uterus Bicornis Duplex.— In this variety of malfor- 
mation development has proceded a step farther than in the 



MALFORMA TIONS OF THE GENITAL ORGANS. 397 

preceding variety. The uterine bodies have become ex- 
ternally united. There is, however, no fusion of the 
cavities. Two cavities are present, opening into a double 
vagina. 

Uterus Bicornis Unicollis. — Here the development 
of the cervix and the lower part of the uterus is normal. 
The upper parts of the body of the uterus have not be- 
come fused, and diverge sharply from each other. The 
organ is two-horned (Fig. 177). 




Fig. 177. — Uterus bicornis unicollis (Winckel). 

Uterus Cordiformis. — In this variety the two halves 
of the uterus are united throughout. Externally on the 
fundus there appears a slight depression, which, with the 
broad body of the uterus, demonstrates the imperfection 
of development. The name is derived from the resem- 
blance to the conventional heart-shape. 

Uterus Septus. — In this variety development has pro- 
gressed so far that externally the uterus presents the nor- 
mal appearance. The septum that divides the two ducts 
has, however, failed to disappear, and a divided uterus 
results. The septum may extend throughout the body 
of the uterus, or it may be less perfectly formed. Often 
one side of the uterus is better developed than the other 
(Fig. 178). 

Malformation of the Vagina. — Malformation of the 
vagina is frequently present with malformation of the ute- 
rus. The septum that divides Miiller's ducts may per- 
sist throughout the whole length of the vagina, forming 
a double vagina; or the septum may have partly dis- 



398 A TEXT-BOOK OF DISEASES OF WOMEN. 

appeared, being present in various stages of perfection. 
In double vagina each orifice may be guarded by a dis- 
tinct hymen. 

Sometimes one of the canals of a double vagina is 
much better developed than the other. The orifice of 




Uterus septus (Cruveilhier). 



the poorly developed canal may be closed at its lower 
extremity, so that the malformation is never recognized 
by the woman or physician unless the closed canal be- 
come distended with blood or other secretion. A variety 
of vaginal cyst may be formed in this way. 

Unilateral Vagina. — In this variety of malformation 
one of the ducts of Miiller fails to develop at all. The 
condition always occurs with uterus unicornis. The 
vaginal canal is smaller than normal and may be situated 
to one side of the median line. 

Absence of the vagina rarely occurs. There may be no 
sign whatever of this structure, or it may be represented 
by a fibrous cord. The external genitals may also be 
absent, or they may be well developed. 

If the uterus and ovaries are well developed, much 
trouble may arise from retention of menstrual blood. 

An attempt should be made, by means of a transverse 
incision between the rectum and the urethra, to reach the 




MALFORMATIONS OF THE GENITAL ORGANS. 2>99 

cervix, and, if possible, to make an artificial vagina by 
transposition of skin from the buttocks. Such treatment 
is usually unsatisfactory, as a patulous canal cannot be 
maintained. It may be necessary to remove the uterus 
and appendages. 

Sometimes the vagina is absent in only part of its 
course, being open below and 
represented above by a fibrous 
cord; or the upper and lower 
portions may be developed, 
while the middle portion is 
imperforate. 

These conditions are more 
amenable to operative treat- 
ment than in the case of com- 
plete absence of the vagina. 
The intervening septum should 

be incised, and the patulous FlG. 179.— Transverse septum of 

condition maintained by the the va s ina (Heyder). 

passage of bougies if necessary. 

Sometimes the lumen of the vagina is obstructed by 
the presence of transverse bands or crescentic folds, which 
have been described as supplementary hymens (Fig. 179). 

A hematocolpos is produced when the vagina becomes 
distended with menstrual blood above such an obstruc- 
tion. 

Hermaphroditism. — A true hermaphrodite is an indi- 
vidual who possesses the organs of both sexes in a condi- 
tion of perfect function. The existence of true hermaph- 
roditism is denied by many authorities of the present 
day, though the older writers firmly believed in it. The 
coexistence of testicles and ovaries has never been proved 
beyond doubt in the human subject. It is doubtful if 
there are any cases, recorded as true hermaphrodites, in 
which the demonstration of the condition is not open to 
serious criticism ; such individuals are in reality pseudo- 
hermaphrodites. The term hermaphrodite is still, how- 



400 A TEXT-BOOK OF DISEASES OF WOMEN. 

ever, very commonly applied to any individual of doubt- 
ful sex. 

A pseudo-hermaphrodite is possessed of a distinct sex, 
and has either ovaries or testicles, though the external 
genitals and other secondary sexual characteristics may 
present the appearance of a double sex. 

In male pseudohermaphroditism the individual has 
testicles, and the external genital organs simulate those 
of the female. 

In female pseudo-herinaphroditism the individual has 
ovaries, and the external genital organs simulate those 
of the male. 

In male pseudo-hermaphroditism the condition of 
hypospadias is usually present, the lower surface of the 
urethra and the perineum being split. The penis may 
be very small and imperforate, the urethra opening at its 
base. The fissure of the perineum closely resembles the 
vagina, and the split scrotum may be mistaken for the 
labia. Cases of this kind are on record in which the in- 
dividuals, ignorant of their true sex, have for years in- 
dulged in sexual connection with men. 

In female pseudo-hermaphroditism there is hypertrophy 
of the clitoris and the prepuce, with approximation of the 
labia majora and contraction or occlusion of the ostium 
vaginae, giving the genitals the appearance of the mascu- 
line type. 

The secondary sexual characteristics of both varieties 
of pseudo-hermaphrodites — the distribution of hair, 
mammary development, shape, voice, etc. — are usually 
of the feminine type. 

It is often exceedingly difficult to determine during life 
the true sex of the individual in cases of hermaphro- 
ditism. The only absolute test of the sex is the determ- 
ination of the genital glands. 

The labia should be carefully palpated to determine 
whether or not testicles are present. Rectal examination 
should be made to determine the existence of uterus or 
ovaries. The sexual inclinations of the individual should 



MALFORMATIONS OF THE GENITAL ORGANS. 401 

be observed. The discharge from the genitals during 
sexual excitement should be examined for spermatozoa. 

The presence of a uterus is not necessarily indicative 
of a female, as a uterus may be associated with a perfect 
penis and testes; and a periodic discharge of blood from 
the genitals has been found in men. 

If conception occurs, of course, all doubt is removed. 
If the sex cannot be definitely determined by such exam- 
ination, it is best to consider the case one of male pseudo- 
hermaphroditism, which is the usual form, and to treat 
the individual as a male. 



26 



CHAPTER XXXIV. 
DISORDERS OF MENSTRUATION. 

Menstruation, or the regular periodical discharge of 
blood from the uterus, is a phenomenon that occurs only 
in the human race and in some monkeys. The anatomi- 
cal changes that accompany menstruation have not yet 
been definitely determined. In some species of monkey 
— Semnopitheciis entellns and Macacus rhesus l — the fol- 
lowing changes appear to take place at the menstrual 
periods : The endometrium first becomes swollen and 
congested as a result of the growth of the stroma, and 
increase in the number and size of the blood-vessels. The 
vessels in the superficial part of the stroma degenerate 
and break down, and blood is extravasated into the 
meshes of the stroma network. The extravasated blood 
collects into lacunae which lie close beneath the uterine 
epithelium. Finally the lacunae rupture and the blood 
escapes into the cavity of the uterus, forming the men- 
strual clot. Then a fresh epithelium grows over the torn 
surfaces, new blood-vessels are formed, the stroma shrinks, 
and the endometrium of the intermenstrual period is 
restored. 

Nothing is known with any degree of certainty re- 
garding the cause and significance of menstruation. 
There is much diversity of opinion in regard to the coin- 
cidence of ovulation and menstruation. Heape has 
shown that for monkeys ovulation and menstruation are 
not necessarily coincident ; in forty-two menstruating 
specimens of £. entellus not one had a recently discharged 
follicle in either ovary. In monkeys, therefore, men- 
struation may take place without ovulation, and it is 

1 Heape, Trans. Obstel. Soc. of London, vols, xxxvi., xl. 
402 



DISORDERS OF MENSTRUA TION. 403 

probable that the same is true for the human female. 
Ovulation and conception may occur in the human female 
when menstruation is absent; pregnancy not infrequently 
occurs during the amenorrhea associated with lactation, 
and in India, where the girls are married at a very young 
age, pregnancy and child-birth occur before menstruation 
has begun. 

Leopold (quoted by Hirst) in an examination of twenty- 
nine pairs of ovaries removed on successive days up to 
the thirty-fifth after a menstrual period, found a Graa- 
fian follicle bursting on the eighth, twelfth, fifteenth, 
sixteenth, eighteenth, twentieth, and thirty-fifth days 
after the menstrual period. Thus ovulation frequently 
occurred without menstruation during the intermenstrual 
interval. In five cases there was no ovulation at the 
menstrual period, or menstruation occurred without ovu- 
lation. 

It seems probable, therefore, that the ripening of the 
ovum in the ovary is independent of the process of men- 
struation, though the increased blood-supply to the gene- 
rative organs during menstruation may, to a certain 
extent, determine the time of ovulation when a suffi- 
ciently ripe ovum is present. 

Though menstruation in women is analogous to the 
rut or " heat " of other animals, yet there are some points 
of difference : The lower mammals breed only at times 
of "heat," and these times of "heat" occur in the wild 
state only at certain periods of the year, which are de- 
pendent upon climatic conditions, the young being born 
at the season of the year best suited for their survival. 
Some domestic animals, like the cow, probably as a result 
of domestication, have no regular breeding time. In the 
lower mammals "heat" and ovulation appear to be coin- 
cident, and these are the only periods during which the 
female seems normally to have any sexual desire. 

The monkeys examined by Heape menstruated through- 
out the year and yet seemed in the free state to have 
definite breeding times. 



404 A TEXT-BOOK OF DISEASES OF WOMEN. 

The human female, with but few exceptions, menstru- 
ates throughout the year and may breed at any time. 
The exceptions in the case of the human female are of 
interest. Dr. Frederick A. Cook, 1 ethnologist to the first 
Peary North Greenland Expedition, says of the Esqui- 
maux living in the extreme north, from the seventy -sixth 
to the seventy-ninth parallels of latitude: " The passions 
of these people are periodical, and their courtship is usu- 
ally carried on soon after the return of the sun; in fact, 
at this time they almost tremble from the intensity of 
their passions, and for several weeks most of their time 
is taken up in gratifying them. Naturally enough, then, 
the children are usually born at the beginning of the 
Arctic night. " In Queensland the natives are also said 
to have a special breeding season. 

Menstruation usually begins in this country at the four- 
teenth year. The time of the first appearance of the 
process is influenced by race, climate, and environment. 
As a rule, it begins earlier in warm climates and later in 
cold climates. It is earlier in girls who lead luxurious, 
indolent lives than in girls of the working classes. 

During the first year or two of menstrual life menstru- 
ation is often very irregular. It may be absent for several 
months after its first appearance, or recur at varying 
intervals before it becomes regularly established. Irregu- 
larity at this time calls for no treatment. 

Precocious menstruation rarely occurs at a very early 
age. It has been known to begin, and to recur with 
regularity, from the time of birth. In such cases there 
is a corresponding premature development of the sexual 
organs. 

The menstrual discharge consists of blood, mucous 
secretion from the uterus and vagina, and epithelial cells 
from the endometrium. 

The normal duration of the flow is from two days to a 
week. The amount of fluid discharged is from 2 to 9 
ounces. Menstruation occurs every twenty-eight days, 

1 New York Journal of Gynecology and Obstetrics, March, 1894, p. 282. 



DISORDERS OF MENSTRUA TION. 405 

counting from the beginning of one period to the begin- 
ning of another. The menstrual interval is subject to 
considerable individual variations, which appear to be 
within the limits of health. It sometimes occurs with 
regularity every two, three, or five weeks. When it 
occurs every two weeks, the alternate flows are often 
but small in amount. The occurrence of, or the attempt 
at, menstruation every two weeks, in a woman who had 
previously menstruated monthly, is sometimes a symp- 
tom of beginning uterine disease. 

Menstruation commonly ceases at about the forty-fifth 
year, when the menopause appears. 

Most of the disorders of menstruation have already 
been considered as symptoms of the various lesions of 
the genital organs that have been described in the pre- 
vious pages. 

There are some disorders of menstruation, however, 
often unaccompanied by discoverable lesions, which now 
demand consideration. 

Amenorrhea. — Amenorrhea is the absence of men- 
struation. Failure of the menstrual blood to be dis- 
charged from the vagina, such as occurs in cases of 
atresia, is not necessarily amenorrhea; menstruation may 
have taken place, though the most marked phenomenon 
of this process, the discharge of blood, is concealed. 

The term primary amenorrhea, or emansio mensiurn, 
is applied to those cases in which menstruation has never 
appeared. Secondary amenorrhea, or suppressio men- 
sium, is applied to those cases in which menstruation has 
ceased after having once been established. 

Amenorrhea is due to defective development of the 
organs of generation; to premature atrophy, such as 
occurs in superinvolution of the uterus; to lesions, 
pathological and traumatic; to acute and chronic general 
diseases; and to psychical disturbances. 

Menstruation is often absent during the acute diseases, 
such as typhoid fever, and it may remain suppressed 
until the general health is fully restored. 



406 A TEXT-BOOK OF DISEASES OF WOMEN. 

Amenorrhea may also occur in any chronic debilitating 
condition. It is common in chlorosis, anemia, phthisis, 
and malaria. 

It frequently results from changes of climate and sur- 
roundings, and continues until the person becomes 
adapted to the new environment. It is seen in emi- 
grants from other countries, and in women who move 
from the country to large cities. It is often caused by 
overwork, physical and mental, and by insufficient food. 
It is not uncommon in studious school-girls. 

Amenorrhea is sometimes due to the excessive general 
development of fat, even in young woman who are ap- 
parently in good general health. 

Amenorrhea is frequently associated with insanity. It 
may be caused by fright, grief, or anxiety. The fear of 
pregnancy after illicit coitus sometimes produces it. 

In some unusual cases amenorrhea is present without 
any discoverable cause. The woman may be in perfect 
general health, and the sexual organs may be well devel- 
oped, at least so far as can be determined by physical 
examination. 

In amenorrhea there is often a general periodical dis- 
turbance that marks the times at which the menstrual 
bleeding should occur. There may be headache, flashes 
of heat, nervousness, nausea and vomiting, and a feeling 
of fulness and pain in the pelvis. Various cutaneous 
eruptions may occur as the result of amenorrhea, as in 
other diseases of the genital apparatus. 

The poor health, mental and physical, that usually ac- 
companies amenorrhea is often thought by the patient 
and her friends to be the result, rather than the cause — 
as it really is — of the arrested bleeding. 

Treatment. — The treatment of amenorrhea depends 
upon the cause of the condition. Little, if any, benefit 
is to be expected in those cases due to defective develop- 
ment of the uterus or the ovaries. If an attempt at men- 
struation is made, as shown by periodical local pain and 
general disturbance, and the uterus is found to be small 



DISORDERS OF MENSTRUA TION. 407 

and sharply anteflexed, benefit may sometimes result from 
thorough dilatation of the cervix. 

Most cases of amenorrhea demand general treatment. 
The mode of life should be regulated according to strict 
hygienic principles. Fresh air, sunshine, baths, and 
suitable exercise should be prescribed. Studious girls 
should be made to lead more active lives. A change of 
surroundings is beneficial. A visit to the seashore and 
salt-water baths are of advantage. 

The general health should be improved by the admin- 
istration of iron, strychnine, or some other tonic. Blaud's 
pill and the hypophosphites are useful. Obesity should 
be relieved by a regulated diet and exercise. The regu- 
larity of the bowels should always be carefully attended 
to. Most of the so-called emmenagogues are of but little, 
if any, value. Benefit is sometimes derived from the use 
of potassium permanganate (gr. j-ij three times a day) 
and the binoxide of manganese (gr. j-ij three times a 
day). These medicines should be administered in pill 
form for several weeks. 

Oxalic acid in doses of from y 1 ^ to \ of a grain, given 
in lemon syrup for a period of from one to four months, 
has been recommended, and is sometimes very useful. 

It seems probable that pelvic massage practised for a 
period of several months may result in benefit. 

Acute suppression of menstruation during a men- 
strual period is a phenomenon to which the term amen- 
orrhea is not properly applicable. It may be caused by 
exposure to cold or by some sudden emotional disturbance 
during the menstrual flow. 

The condition may be unaccompanied by any subjec- 
tive symptoms, or there may be present ovarian and pel- 
vic pain. 

The treatment consists in rest in bed, the application 
of warm fomentations to the lower abdomen, and hot 
foot-baths. Especial care of the general health should 
be observed at the following menstrual period. 

Scanty Menstruation. — Scanty menstruation occurs 



408 A TEXT-BOOK OF DISEASES OF WOMEN. 

when the menstrual flow is much less than normal. It 
must be remembered that individual peculiarities in this 
respect may be within the limits of health. When one 
or more periods are missed, and the flow shows a contin- 
ual tendency to diminish in amount, treatment may be 
demanded. 

The causes and the treatment of scanty menstruation 
are those which have already been considered under 
Amenorrhea. 

Vicarious Menstruation. — Vicarious menstruation is 
the discharge of blood, at the menstrual periods, from 
some part of the body other than the uterus. In some 
cases, instead of a discharge of blood, a secretion of an- 
other character takes place. 

The vicarious discharge may be the only phenomenon 
present, or it may occur supplementary to the normal 
uterine bleeding. 

The vicarious bleeding may take place from almost any 
part of the mucous or cutaneous structures. It occurs 
from the nose, the throat, the lungs, the stomach, the 
bladder, and the anus. It may occur from an ulcer or 
other lesion of the external surface. Sometimes the cu- 
taneous hemorrhages appear in the form of ecchymoses. 

Various secretions may take the place of the bleeding. 
A monthly flow of milk from the breasts has been ob- 
served, and a periodical diarrhea or leucorrhea has taken 
place. 

Vicarious menstruation is a rare condition. It may 
occur in defective development of the uterus and ovaries. 
It is usually found in debilitated nervous women, and ac- 
companies a deficient menstrual discharge from the 
uterus. 

Treatment. — Direct local treatment should be applied 
to the vicarious bleeding only when it becomes excessive. 
The general health of the woman should receive atten- 
tion. Treatment should be applied to any local lesion of 
the genital apparatus that may be discovered. The direc- 
tions given for amenorrhea are also applicable here. 



CHAPTER XXXV. 
THE MENOPAUSE. 

The menopause is the final cessation of menstruation. 
The age at which it occurs is dependent upon a great 
variety of conditions — nationality, climate, mode of life, 
constitutional and local diseases. In the northern coun- 
tries of Europe the menopause is said to appear later than 
in the southern ; in England, later than in America. It 
has been observed that country women menstruate to a 
later age than city women. The woman who bears a 
number of children in rapid succession and suckles them 
not infrequently has a premature menopause. The meno- 
pause may appear early in very fat women and in women 
who are the victims of tuberculosis, nephritis, and dia- 
betes. Disease of the uterus, tubes, and ovaries may 
retard the menopause. In fibroid tumor of the uterus the 
menopause may be delayed for several years. 

In this country the menopause occurs between the 
fortieth and fiftieth years — usually about the age of 
forty-five. 

The menstrual bleeding may gradually diminish in 
amount until it disappears; or it may stop abruptly and 
permanently ; or there may occur one or more intervals 
of amenorrhea of one, two, or three months' duration, 
followed by normal menstrual bleedings, perhaps of 
diminished amount, before the flow finally ceases. 

Profuse bleeding at the time of the menopause and 
slight bleeding occurring more often than monthly 
are, unfortunately, viewed by most women as of no 
moment, and as part of the normal phenomena of 
the change through which they are passing. The same 

409 



4-IO A TEXT-BOOK OF DISEASES OF WOMEN. 

may be said of the apparent reappearance of menstrua- 
tion, or of slight irregular hemorrhages occurring after 
the menopause had been established and menstruation had 
been absent perhaps for many months. These phenom- 
ena are not normal. They should always excite the 
alarm of the woman, and they demand immediate exami- 
nation on the part of her physician. As a rule, the bleed- 
ing is caused by some pathological condition of the ute- 
rus — fungous growths, polypi, fibroids, or cancer. The 
benign lesions may disappear spontaneously with the 
progressing atrophy of the womb, and the hemorrhages 
may cease. Many women undoubtedly recover without 
treatment, and are thus confirmed in the belief that such 
irregular hemorrhages are a normal part of the meno- 
pause ; and the unfortunate women with cancer are thus 
encouraged to delay seeking medical advice until the dis- 
ease has progressed too far for cure. 

The normal changes of the genital organs that begin 
at the menopause are those of atrophy slowly progressing 
to the senile condition. The ovaries atrophy ; the epi- 
thelial elements gradually give place to connective tissue ; 
the Graafian follicles and corpora lutea are destroyed ; the 
tunica albuginea becomes thick and shriveled. The 
uterus diminishes in size ; the vaginal cervix may dis- 
appear ; the utricular glands diminish in size and number ; 
the endometrium atrophies. The Fallopian tubes shrink 
and become shortened, and the fimbriae disappear. Simi- 
lar atrophic changes affect the vagina, the external geni- 
tals, and the mammary glands. 

If the woman is in good general health, and has no 
disease of the uterus, the tubes, or the ovaries, the meno- 
pause may become established without any marked gen- 
eral disturbance. 

In many cases, however, very annoying general symp- 
toms appear, and last for one or two years before the 
woman becomes adapted to the altered conditions. 

There may be headache, flushes of heat, nervous de- 
pression, derangement of the digestive apparatus, and 



THE MENOPAUSE. 411 

other functional disturbance. The woman often becomes 
very fat at this period. The nervous derangement may 
be so severe as to result in insanity. 

The vaso-motor disturbances are often the most annoy- 
ing. The phenomena of the " flushes " consist of a feel- 
ing of heat over the whole or a part of the body, followed 
by sweating and the sensation of cold or a slight chill. 
The flushes may occur frequently during the day, some- 
times several times during an hour. 

The treatment of the menopause should be directed to 
the maintenance of the general bodily and mental health. 
The diet should be carefully regulated. Too much 
nutritious food should be forbidden. Purgatives should 
be administered whenever necessary. The woman should 
have plenty of fresh air and the proper amount of exer- 
cise. Mental depression demands a change of locality 
and surroundings. 



CHAPTER XXXVI. 

GENITAL FISTULA. 

Fistulous openings may exist between the different 
portions of the genital tract and the neighboring struc- 
tures. Such fistulae are the result of childbirth, opera- 
tive or other form of traumatism, congenital defect, can- 
cer, syphilis, or suppuration. The accompanying diagram 
(Fig. 1 80) shows the chief varieties of fistula that occur. 




Fig. 180. — Diagram illustrating the chief varieties of genital fistula: v. u.,. 
vesico-uterine fistula; v. v., vesico- vaginal fistula; u. v., urethro-vaginal fistula; 
r. v., recto- vaginal fistula. 

Vesico-vaginal Fistula.— The most frequent form of 
fistulous opening occurs in the septum between the blad- 
der and the vagina. The condition is usually caused by 
sloughing, the result of prolonged pressure from the fetal, 
head at labor. 

412 



GENITAL FISTULA. 413 

In some cases such an opening is made for therapeutic 
reasons by the physician, for the cure of cystitis. 

Intelligent midwifery and the prompt and proper use 
of the obstetrical forceps have greatly diminished the 
frequency of vesico-vaginal fistula. It was formerly a 
very common disease. At the present day it is but rarely 
seen, at least in those parts of the country where women 
have competent attendance at labor. 

The vesico-vaginal opening may be situated at any 
portion of the septum. It varies very much in size and 
shape. It may be a small hole barely admitting a fine 
probe-point, a median slit, or a large irregular opening 
involving the whole base of the bladder. 

The appearance of the fistula varies according to the 
time that has elapsed since the receipt of the injury. 
The margins of the opening, which are at first irregular 
and ulcerated, become in time thin and firm from cicatri- 
cial contraction, and the size of the opening becomes 
similarly diminished. 

The first symptom of vesico-vaginal fistula is the in- 
voluntary escape of urine from the vagina. If the con- 
dition has resulted from pressure at parturition, the in- 
continence of urine does not appear for five or ten days 
after labor, when the slough has separated. When a 
direct laceration of the vesico-vaginal septum has oc- 
curred, the urine will escape immediately. 

The degree of incontinence varies with the size and 
the position of the fistula. If the opening is small and 
is situated in the upper part of the vagina, there may be 
perfect continence when the woman is in the erect posi- 
tion, as long as the urine remains below the level of the 
opening. Incontinence returns when the accumulation 
of urine becomes greater than this and when the woman 
assumes the recumbent posture. I have seen a woman 
with a fistula of this kind who was only troubled with 
incontinence at night. 

The secondary symptoms of vesico-vaginal fistula are 
due to the irritation of the urine. Unless the greatest 



4 T 4 A TEXT-BOOK OF DISEASES OF WOMEN. 

cleanliness be observed, great suffering may result within 
a few weeks after the receipt of the injury. The vagina, 
the labia, and the inner aspects of the thighs become in- 
flamed and excoriated. The mucous membrane of the 
vagina may become covered with an offensive phosphatic 
deposit. If the fistulous opening be large, the fundus of 
the bladder may prolapse into the vagina and become 
covered with a similar deposit. 

Secondary kidney disease, from infection of the ureters, 
may follow in time. 

As the result of disuse the bladder becomes contracted, 
and its walls become thickened from inflammatory infil- 
tration, so that when the fistula is closed the capacity of 
the bladder is much less than normal. Disuse of the 
urethra results also in contraction, which may be so ex- 
tensive as seriously to complicate treatment. 

Physical examination usually reveals the condition. 
The woman should be placed in the Sims, the genu-pec- 
toral, or the lithotomy position, and the anterior vaginal 
wall should be examined through the Sims speculum. 
The examiner should, of course, determine that the in- 
voluntary flow of urine comes from the vagina, and not 
from the urethra. Women are often unable to tell accu- 
rately whence the urine escapes, and the single symp- 
tom of incontinence of urine is not pathognomonic of 
fistula. 

In most cases the fistulous opening may be readily 
detected, and a sound passed through the urethra may be 
made to emerge in the vagina. In the case of small 
openings, however, obscurely situated in the upper part 
of the vagina, and especially in case of vesico-uterine 
fistula, it may be difficult to demonstrate the presence of 
a fistula. In such cases the bladder may be filled with 
sterile milk, which may then be seen escaping into the 
vagina. This is a valuable method of diagnosis in the 
rare cases of uretero-vaginal fistula. 

Treatment. — The method of curing vesico- vaginal fis- 
tula was taught to the world by Marion Sims, who ope- 



GENITAL FISTULA. 4*5 

rated successfully in 1849, an( ^ wno published his first 
article upon the subject in 1852. 

Careful preparatory treatment before operation is usu- 
ally necessary. Unless the vagina and the bladder are in 
a healthy condition beforehand, every method of opera- 
tion is likely to fail. 

It is necessary to treat all excoriations or ulcerations, 
to cure the cystitis, and to relieve the tension of all bands 
of scar-tissue in the vagina that may prevent proper ap- 
proximation of the edges of the opening. 

The phosphatic deposit should be carefully removed 
from the vaginal walls and the interior of the bladder 
with a soft sponge or cotton, and a weak solution of 
nitrate of silver (gr. v to gj) should be applied to the raw 
surfaces. 

Frequent warm sitz-baths should be administered daily. 
The vagina should be washed out several times a day 
with large quantities of sterile hot water or with a solu- 
tion of boracic acid (3J to the pint). 

The urine, which is generally alkaline, should be ren- 
dered acid by the use of benzoic or boracic acid. 

Emmet advises the following prescription: "2 drams 
of benzoic acid and 3 drams of borax to 12 ounces of 
water, of which a tablespoonful, further diluted, should be 
given three or four times a day. ' ' After the urine has 
become acid the dose may be reduced. 

Ever) 7 fifth day the solution of nitrate of silver should 
be applied to the unhealed, excoriated surfaces. It may 
be necessary to pursue this treatment several weeks be- 
fore the parts are brought to a healthy condition. Im- 
provement is perceived not only in the condition of 
the vaginal walls and the bladder, but in the edges of 
the fistula, which, in place of being hypertrophied and 
indurated, assume a natural color and density. 

In case the vaginal fistula be small, the accompanying- 
cystitis may be difficult to cure, because there is always 
some residual urine in the bladder. It may then be ad- 
visable, as a preparatory step, to enlarge the fistulous 



416 A TEXT-BOOK OF DISEASES OF WOMEN. 

opening by a clean incision in the median line, in order 
to secure more perfect drainage. The cystitis may be 
kept up by the presence of a phosphatic concretion in the 
bladder, which may be removed in this way. It is use- 
less to close the fistula until the cystitis is cured. 

In every case of vesico-vaginal fistula it is advisable 
to examine for vesical calculus, that the bladder may not 
be closed with a calculus in it. The calculus occasionally 
exists before the formation of the fistula, and perhaps as- 
sists in its production, the vesico-vaginal septum being 
squeezed between the child's head and the calculus. Usu- 
ally, however, the calculus forms as a result of the fistula. 
When the parts have been brought to a healthy condi- 
tion the fistula should be examined with a view to the 
method of closure. The opening should be exposed with 
the Sims speculum, and the edges at opposite points 
should be seized with tenacula or forceps and approxi- 
mated. In this way the surgeon may determine the di- 
rection in which the fistula may be closed with the least 
traction on the sutures. When possible, it is advisable, 
in order to prevent shortening of the vagina, to close the 
fistula in the direction of the long axis of the vagina. 

If the edges of the opening cannot readily be brought 
together, any restraining bands of tissue in the vaginal 
walls should be divided with scissors. If these bands are 
slight and superficial, they may be divided at the time of 
operation for closure. If, however, they are extensive, 
preparatory treatment devoted to the liberation of the 
edges of the fistula must be practised. All restraining 
bands should be freely divided, and after the vagina has 

thus been opened up, it 
should be distended (to 
prevent subsequent con- 
traction) by introducing a 
vaginal plug or dilator 

Fig. iSi.-Sims- vaginal dilator. ( Fi ^ lSl ) °f a rubber ba g 

packed with sponges. 
Bleeding is generally controlled by the pressure of the 




GENITAL FISTULA. 417 

plug. The vaginal plugs of glass or of hard rubber are 
made of various sizes. They should be long enough and 
thick enough to stretch the vagina without producing 
sloughing. The plug is retained by a T-bandage. 

After this operation the woman should be kept in bed 
for a week or ten days. The urine should be drawn with 
the catheter without removing the plug. When suppu- 
ration begins the plug will become loosened and may be 
removed. Emmet says: "It is remarkable how much 
absorption of the cicatricial tissue takes place in a few 
weeks when judicious pressure has been maintained by 
this instrument. " 

After removing the plug, vaginal douches should be 
resumed until healing is complete. 

It will be seen from this consideration that the prepara- 
tory treatment may be severe and may extend over a long 
period. Such extensive treatment is not by any means 
always necessary; when, however, it is required, it is use- 
less to proceed to operation without it. 

Operation. — The operation consists in freshening the 
edges of the fistula with the knife or scissors and bring- 
ing them into apposition with the interrupted suture. 
Different forms of suture have been used by various ope- 
rators. If the parts are in a healthy condition and are 
properly denuded and approximated, it makes no differ- 
ence in the result what form of suture is used. As in all 
forms of plastic work, I prefer silkworm gut shotted. 
The operation is most easily performed with the woman 
in the Sims position, the vagina being exposed with the 
Sims speculum. The lithotomy or the genu-pectoral 
position is preferred by some operators. The edge of the 
opening should be seized with the tenaculum or with 
tissue-forceps, and a continuous strip of tissue should be 
removed all around the fistula, extending from the mu- 
cous membrane of the bladder out upon the vaginal sur- 
face for a quarter or three-eighths of an inch. The vag- 
inal mucous membrane usually retracts somewhat as soon 
as it is liberated from the fistulous margin, so that the 

27 




418 A TEXT-BOOK OF DISEASES OF WOMEN, 

raw surface is broader than the strip removed. It is ad- 
visable to avoid any injury to the mucous membrane of 
the bladder, as free bleeding may take place from this 
structure. The denuded surface should extend as near as 
possible to the mucous membrane of the bladder without 
involving it. 

The denudation should be extended some distance be- 
yond each angle of the fistula, in order to secure perfect 
apposition in these positions. 

The length and shape of the needle used for closing 
the opening varies with the fancy of the 
operator. As a rule, a small needle, 
straight or curved at the point, is most 
convenient (Fig. 182). 

The needle should be introduced about 
an eighth of an inch from the edge of 
Fig 182— Fistula- tne vaginal mucous membrane, and 
needles. should be made to emerge at the edge of 

the mucous membrane of the bladder. 
It should be reintroduced and emerge in the reverse order 
on the opposite side (Fig. 183). The sutures should be 
placed about a quarter of an inch apart. 

After the sutures have been introduced, and before 
they have been shotted or tied, the bladder should be 
thoroughly washed out with a warm boric-acid solution. 
The operator should make sure that no blood-clot is left 
in the bladder. After the sutures have been shotted a 
light gauze tampon may be placed in the vagina. 
A permanent soft-rubber catheter may be introduced 
through the urethra, or the urine may be drawn every 
three or four hours after the operation. If care is given 
to the cleanliness of the catheter, it is perhaps best to 
retain it in the bladder for three or four days, after which 
the urine may be drawn every four hours. The catheter 
should be removed twice in twenty-four hours for pur- 
poses of cleansing. The eye of the catheter frequently 
becomes obstructed by blood-clot. 

It should not be forgotten that the bladder is often 
much contracted in old cases of vesico-vaginal fistula, 



GENITAL FISTULsE. 



419 



and as the capacity is diminished more frequent catheter- 
ization than usual is necessary. 

Boric or benzoic acid should be continued during the 
convalescence. 

The gauze tampon should be removed on the second day. 

The bowels should be moved on the second or third 




Fig. 183. — Vesico-vaginal fistula with the sutures introduced. 

day. The sutures may remain for two weeks. The 
woman may sit up at the end of two weeks. 

The operation described here — more or less modified 
in order to meet the requirements of different cases — 
will result in cure in the great majority of instances. 
Often much depends upon the ingenuity and the me- 
chanical skill of the operator. Sometimes two or three 
operations are necessary before the opening can be com- 
pletely closed, the operator closing part at each sitting. 

In the case of a small fistulous opening it may be 
necessary to enlarge it by free incision before the denuda- 
tion and the introduction of the sutures can be properly 
accomplished. 



420 A TEXT-BOOK OF DISEASES OF WOMEN. 

In the very rare cases which are incurable by operation 
kolpokleisis, or closure of the vagina, has been practised 
by some. The operation was performed by removing a 
circular strip around the circumference of the vagina, 
immediately above the ostium vaginae, and approximat- 
ing the raw surfaces by a transverse row of sutures. 
This operation makes of the bladder and the vagina one 
urinary pouch into which menstrual blood and uterine dis- 
charges flow. It should never be practised. I quote from 
Emmet in this connection : ' ' From my own observation 

1 have learned that it is but a question of a few months, 
a year, or possibly two years, before serious consequences 
must arise after leaving a receptacle, like a portion of the 
vagina, in which the urine may stagnate. To give a 
retentive power for so short a time is not a sufficient 
compensation for the suffering and consequences that 
supervene. As the result of my experience, I would 
urge that the operation never be resorted to under any 
circumstances. The maximum has now been reduced to 

2 or 3 per cent, of cases where the resources of the sur- 
geon cannot overcome all the difficulties that may be 
presented in closing a vesico-vaginal fistula." 

The forms of operation in which the cervix uteri is 
utilized to assist in the closure of a vesical fistula, as a 
result of which the menstrual blood and the uterine 
secretions are discharged into the bladder, are contrain- 
dicated for similar reasons. 

Urethro -vaginal fistula is much less common than 
vesical fistula. Unless the neck of the bladder be in- 
volved, there may be perfect control of urine; though, 
of course, when the urine is voided it will escape from 
the ostium vaginae, and not from the external meatus. 

The treatment of urethro-vaginal fistula is essentially 
the same as that already described for vesico-vaginal 
fistula. The edges should be denuded, and the opening 
into the urethra closed over a large-sized catheter. The 
line of union should be in the long axis of the urethra. 

Vesico -uterine Fistula. — In this form of fistula the 
opening usually extends from the bladder into the cervi- 



GENITAL FISTULA. 42 1 

cal canal. It is caused by labor in which the anterior 
lip of the cervix is lacerated. The lower portion of the 
cervical laceration may unite, leaving the fistulous open- 
ing above. 

The diagnosis of the condition is made from observing 
urine escape from the cervical canal, or by injecting the 
bladder with milk or other colored fluid. A sound intro- 
duced in the cervix may be brought in contact with a probe 
passed through the urethra and bladder into the fistula. 

If these methods of examination are not satisfactory, 
endoscopic examination of the interior of the bladder 
will reveal the abnormal opening. 

The treatment consists in dividing the anterior lip of 
the cervix and the vaginal wall down to the fistulous 
tract; thorough denudation of the walls of the fistula; 
and closure of the whole incision by interrupted sutures. 

Uretero-vaginal Fistula. — This condition is usually 
the result of injury to the ureter by operation. It may 
occur from the destruction of tissue caused by pelvic 
abscess, which discharges through the vaginal vault. In 
extensive vesico-vaginal fistula caused by sloughing after 
labor the bladder- wall may become rolled out so that the 
ureter opens into the vagina. 

If but one ureter is involved, one-half of the urine 
will be discharged in the natural way and the other half 
by the vagina. 

The treatment consists in directing the ureter into the 
bladder by plastic operation performed through the va- 
gina; or by performing celiotomy, dissecting out the 
ureter, and implanting it in the fundus of the bladder. 

Recto-vaginal Fistula.— Recto-vaginal fistula is usu- 
ally caused by parturition. The destruction of tissue is 
sometimes due to syphilis. In the latter case cure is dif- 
ficult, and sometimes impossible. 

The spmptom of the condition is the passage of feces 
and flatus into the vagina. 

Sometimes but a very small opening exists, situated im- 
mediately above the sphincter muscle; in other cases the 
greater portion of the recto-vaginal septum is destroyed. 



422 A TEXT-BOOK OF DISEASES OF WOMEN. 

The condition may be recognized by placing the woman 
in the lithotomy position and exposing the posterior vag- 
inal wall by the Sims speculum placed under the pubic 
arch. 

The treatment consists in operation similar to that de- 
scribed under the consideration of vesico-vaginal fistula. 
The woman should be prepared as for a plastic operation 
upon the perineum. The rectum should be thoroughly 
emptied before operating. The sphincter ani should be 
stretched. It is always advisable, when possible, to close 
the opening from the vagina, 

The mucous membrane of the rectum should be in- 
jured as little as possible, in order to limit the bleeding. 
It may be necessary to relieve tension on the edges of the 
fistula by making, on each side of the vaginal aspect of 
the opening, an incision parallel to the long axis of the 
vagina. 

In case of a small fistula situated immediately above 
the sphincter ani, it is sometimes difficult to denude and 
to introduce the sutures. It then becomes necessary to 
divide the perineum and the sphincter ani to the fistula, 
denude the edges, and to introduce sutures as in a case 
of complete median laceration of the perineum. Some- 
times the recto- vaginal fistula is much larger on the vag- 
inal than on the rectal aspect — is, in fact, funnel-shaped, 
the destruction of tissue having been greater upon the 
vaginal surface. If in such a case the edges of the fistuk 
cannot be brought into apposition after freeing all re- 
straining bands, it may be necessary to split the edge of 
the opening, so that the rectal wall is freed and may be 
brought together by sutures introduced through the rec- 
tum, leaving the vaginal opening to be filled by granula- 
tion. The rectal sutures may be introduced by placing 
the woman in the Sims position and exposing the ante- 
rior rectal wall with the Sims speculum. 

The after-treatment resembles in all respects that pre- 
scribed after operation for laceration through the sphinc- 
ter ani. The sutures should be removed in two weeks. 



CHAPTER XXXVII. 
DISEASES OF THE URETHRA AND BLADDER. 

BEFORE considering in detail the diseases of the ure- 
thra and bladder, it will be necessary to describe the 
modern methods of examining these structures. 

The examination of the urethra and bladder has been 
very much facilitated by the methods and instruments 
that have been popularized in this country by Kelly. 
The following apparatus is required: a female catheter; 
a urethral calibrator; a series of specula with obturators; 
a head-mirror and light or an electric headlight ; long, 
delicate toothed forceps (Fig. 184) ; an inclined plane or 




Fig. 184. — Mouse-tooth forceps for bladder. 

several hard pillows for elevating the pelvis; small balls 
of absorbent cotton about the size of a pea, or strips of 
absorbent gauze cut 1 inch in width and about 10 inches 
long, for drying out the bladder. 




Fig. 185. — Urethral dilator : short lines indicate diameter in millimeters. 

The urethral calibrator or dilator (Fig. 185) is a conical 
metal instrument with a maximum diameter of twenty 
millimeters. The diameters in millimeters of the vari- 
ous portions are indicated by numbers upon the instru- 
ment. 

123 



424 A TEXT-BOOK OF DISEASES OF WOMEN. 

The urethral calibrator is useful for dilating the ex- 
ternal meatus to a degree sufficient to admit the necessary 
speculum. The external meatus is, as a rule, the only- 
portion of the urethra that requires dilatation. Any in- 
strument that will pass through the meatus will pass 
through the rest of the canal. 

The speculum (Fig. 186) is a cylindrical metal tube 
fitted with a handle on which is the number indicating 




Fig. 186. — Kelly's cystoscope or vesical speculum. 



the size of the instrument. There are a number of spec- 
ula, varying in diameter from 5 to 20 millimeters. Bach 
speculum is fitted with an obturator. The most useful 
specula are those ranging from 8 to 12 millimeters in diam- 
eter. The urethra may readily be dilated up to 12 milli- 
meters, with little if any, external laceration. Dilatation 
sufficient to admit the largest instrument (20 millimeters) 
is always accompanied by considerable laceration of the 
urethral opening. Dilatation of the urethra should never 
be practised beyond this degree, on account of the danger 
of subsequent incontinence of urine. 

An anesthetic is usually required for the examination, 
unless the woman be capable of enduring considerable 
pain, or has become accustomed to the procedure from 



DISEASES OF THE URETHRA AND BLADDER. 425 

previous experience. Local anesthesia of the urethra 
with cocaine (gr. x to Ij) is often sufficient. 

The woman is placed on the table in the lithotomy 
position, and the bladder is emptied with the catheter. 
The external meatus is then dilated to the requisite size 
by inserting the graduated calibrator with a general ro- 
tary movement. When the meatus has been stretched 
sufficiently, as indicated by the number on the calibrator 
(usually about 12 millimeters), the instrument is with- 
drawn, and the speculum of corresponding number, armed 
with the obturator, is introduced; the obturator is then 
removed. 

The hips of the woman are now elevated on the pillows 
or the inclined plane, or the foot of the table is raised, so 
that the hips shall be from 10 to 20 inches above the level 
of the shoulders. 

The examiner, armed with the head-mirror or light, is 
then prepared to inspect the interior of the bladder. If 
the mirror is used, the light (Argand burner or electric 
drop-light) should be held close to the pubis of the pa- 
tient. 

Usually a small quantity of urine remains in the 
bladder after catheterization, or is secreted during the 
preliminary procedures, and it is necessary to remove 
this before complete examination of the bladder can be 
made. This may be done by means of the small balls of 
absorbent cotton or the strips of gauze grasped with the 




Fig. 187. — Vesical probe or applicator. 

long-toothed forceps and passed in through the speculum; 
or some form of suction apparatus may be employed, 
consisting of a rubber exhaust bulb and a long metal 
tube perforated at the distal end by small openings. 



426 A TEXT-BOOK OF DISEASES OF WOMEN. 

The elevated position of the hips is an essential part 
of this method of examination; it permits the intestines 
to gravitate out of the pelvis, and, as soon as the urethra 
is opened, the bladder becomes distended with air, so that 
all of its interior may be readily inspected, and applica- 
tions to the surface may be directly made through the 
speculum. In some cases it is difficult to produce the 
requisite distention of the bladder by elevating the hips. 
This difficulty may arise in the case of very fat women. 
It then becomes necessary to place the patient in the 
knee-chest position, when the requisite distention is 
readily accomplished. 

As the speculum is withdrawn from the bladder the in- 
ternal meatus and the urethral walls may be examined as 
they fall together beyond the distal end of the instrument. 

DISEASES OF THE URETHRA. 

The female urethra is a musculo-membranous canal 
averaging i^ inches in length, and, when not stretched, 
about % inch in diameter. The urethra is normally closed 
by the apposition of its walls. In the neighborhood of 
the external meatus it is an antero-posterior slit. In the 
neighborhood of the internal meatus it is a transverse 
slit. In the middle portion the mucous membrane is 
arranged in longitudinal folds, and a transverse section, 
shows a stellate closure. 

The muscular coat of the urethra contains both striped 
and unstriped muscular fibers. 

The mucous glands of the urethra are most numerous 
in the region of the external meatus. Skene first de- 
scribed two glands that are worthy of special mention. 
Skene' s glands are two tubules, large enough to admit a 
No. i probe of the French scale, that lie upon the floor 
of the urethra immediately within the external meatus. 
They lie parallel to the long axis of the urethra, and in 
length vary from }i to % of an inch. They are placed 
beneath the mucous membrane, in the muscular coat. 
The orifices of the glands are on the free surface of the 
mucosa, immediately within the external meatus. In 



DISEASES OF THE URETHRA AND BLADDER. 427 

young women the orifices are found about j4 of an inch 
above the plane of the external meatus. If the external 
meatus be patulous, or if there be any prolapse or inflam- 
mation of the mucous membrane of the urethra, the ori- 
fices of Skene's glands may be seen upon each side of 
the urethral orifice as soon as the labia are separated. 
In gonorrhea their position is often indicated by a small 
drop of pus exuding from the orifices. The upper ends 
of the glands may terminate in a number of divisions. 

Urethritis. — Urethritis is much less frequent in women 
than in men. In the great majority of cases it is caused 
by gonorrhea. Aside from microscopic examination, ure- 
thritis, acute or chronic, may be considered one of the 
strongest evidences of gonorrheal infection that we have. 

Urethritis is also rarely caused by the exanthematous 
diseases, irritation of concentrated urine, vaginal dis- 
charges, chemical irritants, and traumatism. 

Symptoms. — The symptoms of urethritis in the acute 
stage of the disease are frequent and painful urination. 
Burning and scalding sensations are experienced along 
the course of the urethra during urination. Occasion- 
ally a few drops of blood escape during or after urina- 
tion. As the disease progresses toward cure or passes 
into the chronic stage, the intensity of these symptoms 
diminishes, and finally they disappear. 

Examination of the parts shows that the external 
meatus is red and swollen. The swollen mucous mem- 
brane may bulge through the opening, giving the appear- 
ance of prolapse. The orifices of Skene's glands may 
be conspicuous. If the woman have not recently uri- 
nated, a drop of pus may appear at the meatus, or it may 
be brought into view by vaginal pressure along the course 
of the urethra. Pressure upon the urethra through the 
vagina causes pain. This is one of the best tests of in- 
flammation of this structure. The urethra may feel 
hypertrophied, indurated, or cord-like to the touch. The 
urethral discharge should always be examined micro- 
scopically for the gonococci. 

In chronic urethritis the subjective symptoms are usu- 



428 A TEXT-BOOK OF DISEASES OF WOMEN. 

ally absent — except, perhaps, frequency of urination. 
The diagnosis is made by physical examination. If the 
woman has not urinated for several hours, the examiner 
will be able to express, by vaginal pressure along the 
course of the urethra, a drop of muco-purulent fluid re- 
sembling the gleety discharge of the male. 

The endoscope reveals the presence of congestion and 
inflammation of the mucous membrane. 

Treatment. — In the acute or the painful stage of the 
disease no local applications should be made. The ex- 
ternal genitals should be bathed several times a day with 
hot water, preferably by means of sitz-baths. Vaginal 
douches are not indicated unless the vagina be involved 
in the inflammation. The vaginal syringe may be the 
means of carrying infection higher up in the genital 
tract. Rest in the recumbent position, if possible, is 
desirable. The diet should be non-stimulating, and 
large quantities of diluent drinks, such as flaxseed tea, 
should be prescribed. The bowels should be kept loose 
by saline purgatives. 

In the subacute or the chronic stages of the disease 
boracic acid (gr. x-xx three or four times a day), salol, 
oil of sandal-wood, cubebs, copaiba, and other drugs 
used for the similar condition in the male are indicated. 
After painful micturition has ceased, the physician may 
make local applications to the urethra, in case the in- 
flammation does not subside satisfactorily without them. 
Such local applications are not always necessary, and 
they may do harm unless proper care is exercised in their 
administration. Asepsis and gentleness are necessary, and 
the applications should never be too strong or irritating. 

Frequent douching of the urethra (two or three times 
a day if possible) with sterile hot water is often of much 
benefit. Skene's reflux catheter should be used (Fig. 
1 88). The shaft of this instrument is fluted or grooved 
to permit the return of the fluid. The catheter should 
be introduced as far as the internal meatus ; a fountain 
syringe should be attached to it, and the urethra should 
be washed out with a quart of hot water. 



DISEASES OF THE URETHRA AND BLADDER. 429 

After the irrigation the catheter should be withdrawn 
and a urethral injection of nitrate of silver (gr. j or ij to 
3j) should be administered. The injection may be given 
by means of a glass pipette the nozzle of which is large 
enough to encircle the external meatus. The nozzle 
should be placed over, not in, the meatus. The female 
urethra will hold about 15 minims of fluid; more than 




Fig. 188.— Skene's reflux catheter. 

this should not be injected. As the condition improves 
the frequency of these treatments may be diminished. 

If the condition does not yield to such treatment within 
a few weeks, application should be made directly to the 
mucous membrane of the urethra through the endo- 
scope. The urethral canal should be washed out as just 
described, and the endoscope should be introduced as far 
as the internal meatus. As it is slowly withdrawn the 
application should be made over the whole inner surface 
of the urethra by a fine applicator wrapped with cotton. 
Nitrate of silver (gr. v-x to Ij) should be employed. 

Sometimes it is found that the suppuration persists in 
Skene's glands. A small drop of pus may be found 
exuding from the orifice of the gland after the rest of the 
urethra has been restored to a healthy condition. In such 
a case the gland should be split up on the urethral sur- 
face by introducing into it one blade of a fine scissors, 
and the tract should be carefully wiped out with pure 
carbolic acid or a strong solution of nitrate of silver. 

In every case of urethritis of gonorrheal origin it is of 
the greatest importance that every trace of the disease 
should be eradicated before the patient gives up treat- 
ment. There is always danger of infection extending to 
the upper parts of the genital tract. 



430 A TEXT-BOOK OF DISEASES OF WOMEN. 

Stricture of the Urethra.— Stricture of the urethra 
in the woman, unlike the similar condition in the male, 
is very rare. It is caused by gonorrhea, injury at child- 
birth or other traumatism, and caustic applications. The 
stricture may exist at any part of the urethral canal. 
The form most usually seen is that which occurs at the 
external meatus, and is caused by the removal of abnor- 
mal growths with caustic or with the knife. 

The symptoms of urethral stricture in women are much 
less marked than those in men. There is frequent and 
difficult urination. Occasionally there is incontinence or 
partial retention of urine. 

If the stricture exist at the external meatus, it may be 
readily seen and its dimensions determined. If it exist 
in the upper portion of the urethral canal, it may some- 
times be felt by palpation along the course of the urethra 
through the vagina, the position of the stricture being 
indicated by local thickening and induration. Its loca- 
tion may also be determined, as in man, by the use of the 
bulbous bougie or sound. 

Treatment. — When the stricture is situated at the ex- 
ternal meatus, it may be divided with the knife or forci- 




Female urethral sound. 



bly stretched. When it is situated in the upper portion 
of the urethra, it is best treated by forcible dilatation. 

The small uterine dilator is the most convenient in- 
strument to use. The dilatation should not extend be- 
yond half an inch, for fear of injuring the urethral walls 
or producing incontinence. In order to prevent contrac- 
tion, it is advisable to pass the large urethral sound (10 
millimeters) at intervals of one or two days after this ope- 
ration, until the patency of the urethra is ensured. 

In some cases the continual subsequent use of the sound 



DISEASES OF THE URETHRA AND BLADDER. 431 

is necessary, as in stricture in the male. The woman 
may be readily taught the use of the instrument herself. 

Prolapse of the Mucous Membrane of the Ure- 
thra. — Prolapse of the urethral mucous membrane is of 
unusual occurrence. Prolapse may be limited to part of 
the circumference of the meatus, or it may extend around 
the whole canal. The condition is usually found in weak, 
debilitated women. It may occur during childhood. 

The prolapse may be caused by dilatation of the ure- 
thra and the external meatus or by the traction of a neo- 
plasm of the urethra. It sometimes occurs after labor. 
It may be produced by continual vesical tenesmus, the 
result of cystitis, calculus, or a tumor of the bladder. 

The symptoms, vesical tenesmus and dysuria, are usu- 
ally present. Sometimes incontinence of urine occurs. 
The protruding mucous membrane may become irritated 
and inflamed, and cause much local pain. It has been 
known to slough off. 

Treatment. — The treatment should be directed, in the 
first place, to the relief of any causative condition, such 
as cystitis or calculus. 

Inflammation of the protruding mucous membrane 
should be relieved by local applications of hot water and 
by rest in bed. The mucous membrane should then be 
gently replaced within the urethra, and contraction of 
the canal should be promoted by the use of astringent 
injections of tannic acid or alum. 

If the disease does not yield to this treatment, the pro- 
lapsed mucous membrane should be excised, and the edges 
of the mucosa should be stitched to the margin of the 
meatus by fine suture. 

After this operation there is sometimes cicatricial con- 
traction of the external meatus, which may readily be 
cured by forcible dilatation. 

Vesico-urethral Fissure. — Vesico-urethral fissure is 
an ulcerated crack of the mucous membrane situated at 
the internal urinary meatus. The upper portion extends 
into the bladder, the lower portion is in the urethra. 



43^ A TEXT-BOOK OF DISEASES OF WOMEN. 

Skene describes it as "from \ to f of an inch in 
length, and from ^ to £ of an inch in width at the cen- 
ter, but tapering off at each end. The deepest part has 
a yellowish-gray color, like that of an indolent ulcer, 
while the edges are red and actually inflamed, like those 
of an irritable ulcer." 

Vesico-urethral fissure is usually caused by urethritis. 
It may also result from injuries during confinement or 
from the bungling use of the catheter. 

Symptoms.— There is a constant desire to urinate, and 
urination is followed by severe tenesmus. There is a 
burning pain at the neck of the bladder, increased im-" 
mediately after urination. Pressure upon the internal 
meatus through the vagina may cause lancinating pain. 




Fig. 190. — Skene's urethral endoscope. 

The symptoms resemble closely those of urethritis and 
cystitis. 

The diagnosis of vesico-urethral fissure can be made 
with certainty only by seeing the fissure through the 
endoscope. The existence of the condition may be sus- 
pected in a woman who presents the symptoms just de- 
scribed, and in whom no signs of inflammation or other 
disease of the urethra or the bladder can be detected. 

The open endoscope is not satisfactory for detecting 
this condition, because the fissure is bidden from view by 
the folds of mucous membrane at the upper end of the 
instrument. Skene, who has especially directed atten- 
tion to vesico-urethral fissure, states that he never was 



DISEASES OF THE URETHRA AND BLADDER. 433 

able to detect the lesion until he used the form of endo- 
scope introduced by him (Fig. 190), which consists of a 
small glass tube like the ordinary test-tube, into which 
is passed a mirror on a holder. The instrument is passed 
into the urethra, and light is thrown in by means of the 
concave head-mirror. By moving the small mirror in 
the tube, different parts of the urethral walls may be ex- 
amined. The instrument opens out the folds of mucous 
membrane immediately above the fissure and renders it 
visible. 

Treatment. — The cure of vesico-urethral fissure is often 
difficult. The lesion is exposed to continuous irritation 
from the urine and from the sphincteric action of the 
muscular fibers at the vesical neck — an action which is 
much increased by the tenesmus present. This constant 
muscular action impedes healing, as in the case of fissure 
of the anus. The internal urinary meatus should be 
dilated under anesthesia to the extent of y& inch by 
means of the graduated bougies or the uterine dilator. 
After dilatation the woman should be kept in bed and 
the urine should be rendered as unirritating as possible by 
the use of diluent drinks and boracic acid. 

If this treatment does not result in cure, a vesico- 
vaginal fistula should be made, so that, by carrying off 
the urine by this means, rest from functional activity will 
be furnished to the region of the vesical neck. 

No effort need be made to keep the fistula open, as by 
the time it has closed spontaneously the fissure will have 
healed. 

Dilatation of the Urethra.— Dilatation of the urethra 
producing symptoms that require treatment is unusual. 
It may be due to congenital defect, to spontaneous expul- 
sion, or instrumental extraction of a calculus or tumor 
of the bladder, to excessive dilatation by the surgeon; 
and it may occasionally follow pregnancy. Skene says, 
"the hyperemia of the urethra which occurs in preg- 
nancy and which tends to produce overdistention of the 
veins favors dilatation of the whole urethra." 

28 



434 A TEXT-BOOK OF DISEASES OF WOMEN. 

The urethra may be so dilatable that it will admit the 
penis — coitus having been practised in this way in a num- 
ber of instances. 

In dilatation of the urethra there may be continuous 
incontinence of urine, or the urine may escape only dur- 
ing acts of straining, coughing, or lifting. 

The condition may be determined by the insertion of 
sounds or the finger. 

Treatment should be directed to the cure of any 
inflamed condition of the urethra which may accompany 
dilatation, and to the use of astringent injections of tan- 
nic acid. 

If incontinence of urine persists it may be necessary to 
perform a plastic operation, excising a portion of the 
anterior wall of the vagina and the posterior wall of the 
urethra, and closing the wound by transverse sutures. 

In urethrocele the dilatation is confined to a portion of 
the urethra, usually the middle third. There is a saccu- 
lated condition of the posterior wall of the urethra extend- 
ing into the vagina. The usual cause of this condition 
is traumatism during labor. The symptoms are painful 
and difficult micturition and partial incontinence of urine. 
The condition may be diagnosed by the use of the sound 
or the probe, which may be inserted in the sac through 
the urethra, when the point may be felt by a finger on the 
anterior vaginal wall. Sometimes the urethrocele pro- 
duces a distinct bulging in the anterior wall of the vagina. 

If the annoying symptoms of urethrocele continue 
after any accompanying inflammation of the urethra has 
been relieved, it may be necessary to excise the saccu- 
lated portion of the urethra by incision through the vag- 
inal wall and close the wound by suture. 

URETHRAL NEOPLASMS. 

Urethral Caruncle. — The urethral caruncle is a small 
raspberry-like tumor situated at or just inside of the ex- 
ternal meatus. It is composed of dilated capillaries set in 
a dense stroma of connective tissue and covered with 



DISEASES OF THE URETHRA AND BLADDER. 435 

mucous membrane. The tumor varies in size from a 
pin-head to a hickory-nut. In color it varies from a pale 
to a bright red. It is usually situated upon the posterior 
wall of the urethra. There may be two or more such- 
tumors around the circumference of the meatus, and oc- 
casionally they are found in the vestibule. The growth 
is usually sessile. 

The caruncle is often erectile in character, and increases 
in size at the menstrual period. 

The growths bleed very easily on manipulation, and 
are exquisitely sensitive. The urethral caruncle is the 
commonest neoplasm of the urethra. 

Symptoms. — The most marked symptom of urethral 
caruncle is pain. Intense pain is experienced at mictu- 
rition and upon contact with the clothing or other body. 
Sexual connection is sometimes rendered impossible. 

There is usually more or less hemorrhage from the 
tumor, which may rarely be so profuse as to cause marked 
anemia. The general health suffers, and nervous symp- 
toms, resulting from the pain and loss of sleep, are often 
present to a pronounced degree. 

Treatment. — The treatment consists in the total ex- 
tirpation of the growth. It should be picked up with 
forceps and excised with the knife or scissors. The edges 
of the mucous membrane should be united by sutures. 

Excision should be complete or the tumor may return. 
In case of recurrence a second operation should be per- 
formed. 

Urethral Cysts. — Small cysts are occasionally found 
in the course of the urethra. They may occur at any 
point from the internal to the external meatus. They 
are caused by obstruction and distention of the urethral 
glands. They produce no symptoms unless large enough 
to cause obstruction to the flow of urine. They may be 
seen by the endoscope or may be palpated through the 
vaginal wall. 

The treatment consists of incision and removal of part 
of the cyst-wall. 

Polypus. — Mucous polyp of the urethra is of very rare 



43 6 A TEXT-BOOK OF DISEASES OF WOMEN. 

occurrence. The tumor generally has a delicate ped- 
icle, and may protrude from the meatus. It is painless, 
and causes discomfort only by obstructing the flow of 
urine. 

The treatment consists of removal by torsion, ligature, 
or excision. 

Sarcoma and cancer of the urethra have rarely been 
observed. The phenomena are those similar to cancer in 
other parts of the body. 

The treatment consists in thorough removal. 

DISEASES OF THE BLADDER. 

The urinary bladder has three coats — an outer incom- 
plete peritoneal investment, a middle muscular coat, and 
an inner lining of mucous membrane. 

The empty bladder is always collapsed, its walls being 
in apposition. A median sagittal section of the bladder 
and urethra shows a Y-shaped fissure lying between the 
symphysis pubis and the uterus, the uterus lying ante- 
verted upon the upper surface of the bladder. 

For convenience of description the bladder is divided 
into three parts — the corpus, or body, the fundus, or base ; 
and the cervix, or neck. 

The body of the bladder is all that portion that lies 
above the plane of the vesical orifices of the ureters and 
the center of the symphysis pubis. 

The part lying below this plane is the base. 

The vesical triangle, or the trigone, is that triangular 
area in the base of the bladder, the angles of which are 
marked by the vesical orifices of the ureters and the in- 
ternal meatus of the urethra. 

The neck of the bladder is the funnel-shaped portion 
where the bladder merges into the urethra. 

The mucous membrane of the bladder is covered partly 
with squamous, partly with cylindrical epithelium. The 
mucous membrane is loosely attached to the muscular 
coat throughout the body of the bladder, so that when 
the organ is contracted the membrane is thrown into un- 



DISEASES OF THE URETHRA AND BLADDER. 437 

even folds. The mucous membrane is much more closely 
attached to the underlying structures in the region of the 
vesical triangle, and it here preserves a smooth surface 
when the bladder is collapsed. 

The vesical triangle is more richly supplied with 
nerves than are the other portions of the bladder, and is 
consequently the most sensitive portion. 

The vesical orifice of the ureter appears as a dimple, a 
small truncated cone, or a pin-hole or slit on the mucous 
membrane. 

A transverse band or fold of mucous membrane, known 
as the intra-ureteral ligament, extends between the ori- 
fices of the ureters. 

The dimensions of the vesical triangle are subject to 
individual variations. The triangle is usually equilateral, 
its sides varying from i to i^ inches in length. The 
vesical orifices of the ureters are therefore situated at 
points lying from ^ to ^ of an inch from the median 
line — a useful fact to remember in opening the bladder 
through the vagina. 

The vascular supply of the bladder is intimately asso- 
ciated with that of the uterus — a fact that explains the 
sympathetic disturbance of the bladder in uterine dis- 
ease. The interior of the normal bladder is of a dull 
gray-red color. When distended, as in making an endo- 
scopic examination, the minute arteries and veins may 
be plainly seen upon the surface. 

The pressure of the urine in the bladder may be deter- 
mined by the manometer. In the erect posture the intra- 
vesical pressure has been found to vary from 12 to 16 
inches of mercury. In the recumbent posture the pres- 
sure is reduced to from 4 to 6 inches. 

Cystitis. — Cystitis, especially of the subacute or the 
chronic form, is a common disease in women. The 
pathological changes resemble those seen in inflamma- 
tion of mucous membrane in other parts of the body. 

In the acute stage the mucous membrane is swollen 
and relaxed, and of a deep-red or hyperemic appearance. 



438 A TEXT-BOOK OF DISEASES OF WOMEN. 

Partial exfoliation takes place. The surface may be 
covered with thick, tenacious mucus or pus. 

In the chronic stage the mucous membrane is of a 
muddy gray color, and may be more or less covered with 
a mucopurulent secretion. Ulceration, superficial or 
deep, may occur. The ulcer is sometimes deep and 
ragged and extends into the muscular wall. 

In chronic cystitis we often find on the surface of the 
mucous membrane small localized areas of inflammation 
varying in size from y 2 inch to 2 inches in diameter, and 
presenting a congested, granular, or eroded appearance, 
while the rest of the mucous membrane appears perfectly 
normal. These areas of inflammation bleed readily when 
touched. They are most often found in the base of the 
bladder, though they may occur in any part. When 
chronic cystitis is limited, it is usually confined to the 
vesical triangle. 

The outer coats of the bladder may be involved in the 
inflammatory process, and become much thickened and 
hypertrophied. The ureters and the kidneys may be- 
come in time affected, through direct extension of the 
inflammation in the form of a ureteritis and pyelitis, or 
through obstruction of the vesical orifice of the ureters 
from inflammatory thickening. The alteration in the 
character of the urine is usually marked except in the 
mild forms of chronic inflammation. The specific grav- 
ity is low, varying from 1005 to 1018. In the chronic 
disease the urine is alkaline and ammoniacal. It con- 
tains blood, mucus, pus, and epithelial cells from the 
vesical mucosa. 

Cystitis in women is usually caused by infection at 
catheterization. The very great improvement in the 
asepsis of this procedure that has taken place in recent 
years has in a corresponding degree diminished the fre- 
quency of cystitis. 

Infection at catheterization is caused not only by the 
use of a dirty catheter, but by the conveyance of septic 
material from the external genitals or the urethra into 



DISEASES OF THE URETHRA AND BLADDER. 439 

the bladder. For this reason the nurse or the physician 
should never pass the catheter by touch, as was some- 
times formerly taught. The parts should be exposed to 
view, and the external genitals, vestibule, and meatus 
should be cleansed. 

Cystitis may also be caused by extension of urethritis; 
by inflammation of adjacent organs; by abnormal urine; 
by constitutional diseases, as the exanthemata; by in- 
juries to the bladder and displacement of this organ; 
and by retention of urine. 

Symptoms. — The symptoms of cystitis vary with the 
stage and the character of the affection. Pain, frequent 
urination, and tenesmus are usually present. 

In the acute stages there may be an elevation of 
temperature. There is a feeling of fulness in the 
bladder, with pain in the region of this organ. The 
pain is increased by motion and by the erect position, 
which increases the intra-vesical pressure. The pain 
is constant, and is not relieved by evacuation of the 
bladder. Pressure upon the base of the bladder through 
the vagina causes pain. This is a useful diagnostic point. 
There is a frequent desire to urinate, and the passage of 
urine is followed by straining efforts or tenesmus. The 
alteration in the character of the urine has already been 
mentioned. 

In time the general system suffers from secondary renal 
disease and from absorption, through the bladder, of the 
ingredients of decomposed urine and septic material from 
the mucous membrane. 

The diagnosis of cystitis is easily made by proper ex- 
amination. It should always be remembered that not 
every woman who complains of painful and frequent 
urination and vesical tenesmus is necessarily suffering 
with cystitis. These symptoms are often caused by dis- 
ease of the urethra, by displacement of the uterus, which 
drags upon the neck of the bladder, by the pressure of a 
tumor, or by displacement of the bladder such as may 
follow laceration of the perineum. 



440 A TEXT-BOOK OF DISEASES OF WOMEN. 

Women may often be seen who have been treated for 
weeks for cystitis without avail, and who are immediately 
relieved of all symptoms by the replacement of a retro- 
verted uterus or the closure of a torn perineum. These 
conditions may in time result in cystitis, but the disease 
usually disappears with the cure of the causative lesion. 

It is of the first importance, therefore, for the physician 
to make a careful pelvic examination, and to exclude all 
conditions that might cause irritation of the bladder. 
Microscopic examination of the urine, by revealing the 
presence of pus and blood and the epithelial cells of the 
bladder, is of value in making a diagnosis. The urine 
for examination should be drawn with the catheter, to 
prevent contamination from vaginal discharges. 

Examination of the urine does not, as a rule, enable 
one to exclude inflammation of the ureters or of the pel- 
ves of the kidneys. If there is any doubt, it may be re- 
moved by the use of the endoscope, which will reveal the 
true condition of the bladder-wall. 

As has already been said, tenderness upon pressure 
through the vagina on the base of the bladder is of diag- 
nostic value in determining the presence of cystitis. In 
the mild forms of chronic cystitis — those characterized by 
local areas of inflammation — examination of the urine 
may throw no light upon the condition, as the secretion 
of pus or mucus is very slight. The diagnosis can then 
be made only by means of the endoscope. 

It is perhaps advisable in all cases of chronic cystitis to> 
use the endoscope, not only to confirm the diagnosis, but 
to begin the treatment by making direct local applica- 
tions. 

Treatment. — The treatment of cystitis is general and 
local. Local treatment should never be used in the acute 
stages of the disease. Many cases recover completely 
without any local treatment whatever. 

In acute cystitis the woman should be put to bed. The 
irritation of the bladder is much relieved when the intra- 
vesical pressure is thus diminished. 



DISEASES OF THE URETHRA AND BLADDER. 441 

The diet should be carefully regulated, all stimulating 
ingredients being withdrawn. An exclusive milk diet is 
the best. 

Saline laxatives should be administered, and continued 
to the point of mild purgation. One dram of Rochelle 
salts every two or three hours, given in -half a tumbler- 
ful of soda-water, is useful for this purpose. Large 
quantities of diluent drinks should be given, such as flax- 
seed tea or Vichy water. 

If the urine is acid, citrate of potassium may be ad- 
ministered with the diluent drinks, so that from 1 to 2 
drams of the salt are taken during the day. Bicarbonate 
of potassium in similar doses is also useful. 

When the urine becomes ammoniacal, boracic acid, in 
doses of 10 grains from three to six times a day, is most 
useful. Benzoic acid, in doses of 10 grains three or four 
times a day, is also valuable. 

A very good method is to make a pint or a quart of 
flaxseed tea, to dissolve in it the requisite amount of 
citrate of potassium or of boracic acid (as the urine is 
acid or alkaline), and to administer this in divided doses 
during the day. This treatment, with rest in bed, should 
be continued as long as the vesical pain and tenesmus 
continue. 

If the pain and tenesmus are severe, small doses of 
opium may be given. It is, however, not advisable to 
use opium unless the suffering of the woman demands it. 

If the disease, as the symptoms become less acute, does 
not progress satisfactorily toward cure, medicines that 
have a more stimulating effect upon the mucous mem- 
brane should be given, such as cubebs and copaiba, oil 
of turpentine, oil of eucalyptus, and oil of sandalwood. 

Many cases of acute cystitis, if carefully treated in this 
way, will recover completely without the use of local 
treatment. If, however, the disease does not yield to 
these measures, local treatment becomes necessary. 

In many instances the woman first comes under treat- 
ment when the disease has reached a chronic stage; or it 



442 A TEXT-BOOK OF DISEASES OF WOMEN. 

may be that the disease has begun subacutely, and has 
gradually progressed without having presented any 
symptoms of acute onset. L,ocal combined with gene- 
ral treatment is then often advisable from the beginning. 
Local treatment consists of general applications made 
to the whole of the interior of the bladder through the 
catheter; direct application, limited to the diseased por- 




FiG. 191. — Apparatus for washing the bladder. 

tions of the mucous membrane, through the endoscope; 
and operation, or the formation of a vesico- vaginal fistula. 

Washing out the bladder with sterile warm water, 
either pure or medicated, is often very useful. Gentle- 
ness in manipulation and asepsis should be carefully ob- 
served in this procedure, or much more harm than good 
may result from it. The operation, if properly performed, 
should never give pain to the woman. 

A very simple apparatus is required, consisting of a 



DISEASES OF THE URETHRA AND BLADDER. 443 

soft-rubber catheter, of moderate size, attached to a small 
glass funnel by means of a rubber tube and a piece of 
glass tubing. The whole is about 2 feet long (Fig. 191). 

The catheter, slightly lubricated at the point, should 
be gently introduced into the bladder, and the urine 
should be slowly withdrawn. As the urine flows into the 
funnel its character may be observed. The rapidity of 
the flow of the urine may be regulated by raising or low- 
ering the funnel. As the last portion of the urine is 
withdrawn the flow should be very slow, in order to pre- 
vent injury to the vesical mucous membrane from drag- 
ging it into the eye of the catheter. 

When the bladder is emptied, sterile hot water may be 
introduced through the funnel and the process of with- 
drawal repeated. The mucus, pus, or blood which had 
remained in the bladder after evacuating the urine may 
be examined as the water flows into the funnel. This 
process may be repeated several times if necessary to 
wash out the bladder. The water should be about the 
temperature of the body (ioo° F.). It is less irritating 
to the mucous membrane if there is dissolved in it boracic 
acid or common table salt, about 1 dram to the pint, 
though these ingredients should not be added if they 
act chemically on the substances subsequently used in the 
medicated solution. 

The quantity of water introduced into the bladder may 
be regulated by the feelings of the patient. The disten- 
tion of the bladder should never be great enough to cause 
pain. Usually an ounce of fluid is all that can at first 
be tolerated without producing pain. As improvement 
takes place more fluid may be introduced in the subse- 
quent treatments. 

After the bladder has been washed out in this way, 
applications may be made to the interior by pouring 
through the funnel the desired medicated solution, the 
most useful one being a weak solution of nitrate of silver 
(gr. j or ij to sj). This solution should be retained in the 
bladder for a few minutes, and should then be withdrawn. 



444 A TEXT-BOOK OF DISEASES OF WOMEN. 

A solution of sulphate of copper (gr. j-iv to Ij) is also 
useful. 

At first daily irrigation and application should be thus 
practised. As the case improves the intervals between 
the treatments should be lengthened. 

This local treatment should always be combined with 
the general treatment already prescribed — rest in bed if 
possible, a milk diet, and the administration of boracic 
acid internally. 

Application through the Endoscope. — If the endoscope 
is used in the first place for diagnosis in a case of chronic 
cystitis, much time that might otherwise be wasted in 
unnecessary or useless forms of treatment may be saved. 
The condition of the parts may be accurately determined, 
and the proper form of treatment may be instituted. It 
may, for instance, be seen that deep ulceration is present, 
or that other lesions of the bladder are so extensive that 
the quickest plan of cure will be to proceed immediately 
to the formation of a vesico-vaginal fistula, without at- 
tempting to treat the disease by applications. 

Applications may be readily made, through the endo- 
scope to any part of the interior of the bladder. Appli- 
cations made in this way are most useful when the dis- 
ease is localized. Stronger solutions may be used on the 
affected areas than when the application is made to the 
whole surface of the organ. 

When the disease is limited to the vesical triangle or 
to local areas situated elsewhere, the inflamed spots 
should be touched with a solution of nitrate of silver 
(gr. v-xx to Sj). Much benefit is frequently derived from 
one such application, in connection with the general 
treatment already indicated. The applications may be 
made every few days. The procedure causes less discom- 
fort to the woman as she becomes accustomed to it. 

Cystotomy. — In cases of ulceration of the mucous mem- 
brane, or when the disease has resisted the milder forms 
of treatment, it may become necessary to perform cystot- 
omy, to furnish an opening for the continuous drain of 



DISEASES OF THE URETHRA AND BLADDER. 445 

the urine, and to put the bladder at rest by relieving it 
from all functional action. This is a most valuable ther- 
apeutic operation in cases of obstinate cystitis. 

In performing cystotomy the anatomical relations of 
the ureters and the internal orifice of the urethra must 
be kept in mind. It will be remembered that the ureters 
terminate in the bladder at points situated from y 2 to % 
of an inch from the median line. 

The course of the urethra is indicated by the anterior 
vaginal column, which is a single or double thickening 




FlG. 192. — Illustration of the position of the incision in vaginal cystotomy, 
and the relations of the urethra and the ureters : A, anterior vaginal column ; 
B marks the position of the internal urinary meatus ; C and D mark the orifices 
of the ureters. The distance from C to D varies from I to \\ inches. C, B, D 
is approximately an equilateral triangle. 



of mucous membrane traversed by short transverse folds 
or ridges. It begins near the external meatus and extends 
upward for about an inch. The internal meatus may be 
very approximately located by the upper end of this an- 
terior vaginal column. The incision into the bladder 
should be made in the median line above this point. 



446 A TEXT-BOOK OF DISEASES OF WOMEN. 

The operation should be performed under the influence 
of an anesthetic. The woman should be placed in the 
Sims or the dorso-sacral position. The anterior vaginal 
wall should be exposed with the Sims speculum. A 
sound should be passed into the bladder, and its point 
should be pressed against the posterior vesical wall 
toward the vagina, at the position where the incision is 
to be made. The incision should be made into the blad- 
der through the tissues fixed on the point of the sound. 
The opening may then be enlarged with the knife or 
scissors. The opening should be from i toi^ inches in 
length. In order to prevent spontaneous closure of the 
fistula, the mucous membrane of the bladder should be 
sutured to the mucous membrane of the urethra around 
the margin of the fistula. 

The after-treatment consists in daily washing of the 
bladder with large quantities of sterile warm water or 
with the boracic-acid solution. The woman should be 
placed in the dorso-sacral position, and the fistulous open- 
ing should be exposed by the Sims speculum. The water 
should be introduced into the bladder through the ure- 
thra. Care must be taken to hold the edges of the fistula 
open, so that there may be a free channel of escape. 

The patient should at first remain in bed. After the 
acute symptoms have disappeared she may get up and 
the frequency of the local treatments may be diminished. 
Various appliances have been introduced for receiving 
the continuously escaping urine. None of them, how- 
ever, are satisfactory. They are difficult to keep clean, 
they cause pain, and they are liable to become displaced. 
The best method is to wear a vulvar pad of some absorb- 
ent material and to pay strict attention to cleanliness. 
The progress of the case may be determined by exami- 
nation of the urine, and by examination of the vesical 
mucous membrane through the fistula or through the 
endoscope. 

The time required for cure may extend from one to six 
months. 



DISEASES OF THE URETHRA AND BLADDER. 447 

When the vesical membrane has been restored to a 
normal condition the fistula may be readily closed. 

Vesical Calculus. — Stone in the bladder is less com- 
mon among women than among men. This fact is prob- 
ably due to the greater size and dilatability of the female 
urethra, on account of which small calculi may readily 
pass out. 

The symptoms and methods of diagnosis of vesical 
calculus are similar to those in the male. The stone 
may often be palpated by bimanual examination. 

Treatment. — Small stones uncomplicated with cystitis 
may be crushed and removed through the urethra. L,arge 
stones should be removed by cystotomy. Whenever 
cystitis is present, it is advisable to perform cystotomy 
and to make a permanent fistula until the cystitis is 
cured, when the opening may be readily closed. 



CHAPTER XXXVIII. 
GONORRHEA IN WOMEN. 

Gonorrhea in women has been considered discon- 
nectedly in the preceding pages as one of several patho- 
logical conditions that affect the different parts of the 
genital tract. A more connected discussion of the sub- 
ject will be of value, in view of the frequency of the 
disease, its often unsuspected or insidious character, and 
the serious and fatal lesions that it may produce. Lying 
between the two specialties of venereal diseases and gyne- 
cology, it is often ignored or slighted by both. 

Acute gonorrhea in the female is much less frequent 
than in the male. It is rare in the gynecological dispen- 
saries of Philadelphia to see acute gonorrhea of any 
part of the geni to-urinary tract. 

The disease is very often subacute or chronic from the 
beginning, and is not, as in the male, always preceded 
by a period of acute invasion, the symptoms of which 
necessarily attract the attention of the patient and the 
physician. For this reason gonorrhea in the woman is 
very often overlooked. We can as yet form no accurate 
estimate of its frequency. Certain lesions, such as pyo- 
salpinx, which may be the remote result of gonorrhea, 
are often, especially by gynecologists, indiscriminately 
attributed to this disease without anything like sufficient 
evidence of such a causative relation. 

The fact that the husband may at some time of his 
life have had gonorrhea, or even that the woman may 
have had gonorrhea, is no evidence that a pyosalpinx 
that appears in later years has been caused by this dis- 
ease. There are many other causes of pyosalpinx be- 
sides gonorrhea. The frequent causative relation of sep- 

448 



GONORRHEA IN WOMEN. 449 

sis at labor, miscarriage, or criminal abortion, or during 
the intra-uterine manipulations of the physician, should 
always be remembered. 

I have no intention of underrating the danger to the 
woman of coitus with a man who is not entirely cured 
of a gonorrhea or a gleet. The lives of a great many 
women have been ruined by marriage with incompletely 
cured gonorrheal husbands, and but very few men in such 
a condition would contemplate marriage if they were 
aware of the danger to the woman that results from such 
an act. But, on the other hand, men who are at all care- 
ful of themselves are, without doubt, usually completely 
cured of gonorrhea; and there are thousands of men in 
the community who have had one or more attacks of 
gonorrhea before marriage, and who have now healthy 
and prolific wives. Every physician of experience will 
find such examples in the circle of his own practice or 
acquaintance. It is very unscientific to lay the responsi- 
bility upon such husbands for every pelvic inflammatory 
condition that may appear in their wives. 

The difficulty of proving the presence of gonorrhea in 
women is often very great. As has been said, the disease 
may begin and may exist for a long time without attract- 
ing the attention of the woman. She often pays no at- 
tention to a slight burning or tickling sensation in the 
urethra, which passes off in a few days. She may have 
had a leucorrheal discharge for a long time, and she may 
fail to notice any slight alteration in its character or quan- 
tity that may have been caused by gonorrhea. 

There is nothing in the gross appearance of the dis- 
charge from any part of the genital tract which is abso- 
lutely pathognomonic of gonorrhea. The condition may 
be suspected if there is a purulent discharge from the 
urethra, because urethritis in women is very generally of 
gonorrheal origin. But, on the other hand, there may be 
an innocent-looking mucous discharge from the cervix, 
such as occurs in health or in mild non-specific condi- 
tions, yet in which gonococci may be found. 



29 



450 A TEXT-BOOK OF DISEASES OF WOMEN. 

The presence of the gonococcus is, of course, positive 
evidence of gonorrhea. But this organism may be pres- 
ent in small numbers and escape detection even at the 
hands of experienced observers; or it may be present in 
the tissues of the infected region and fail to appear in 
the discharge; or it may in time itself disappear alto- 
gether. And thus, when the woman begins to suffer from 
some of the remote lesions of gonorrhea, such as an en- 
dometritis or a salpingitis, and is driven to seek medical 
advice, she ma}' be unable to give any history whatever 
of the beginning of the disease; the character of the 
secretions may teach the physician nothing; the gono- 
coccus may have disappeared from the genital discharge; 
and though a pyosalpinx may be present which had 
originally been caused by gonorrhea, yet the gonococcus 
may likewise have disappeared from the tubal pus, and 
other pathogenic organisms may be found in its place. 
It becomes impossible to determine the true origin of the 
disease. 

For these reasons, if the physician is accurate in his 
observations, and classifies as gonorrheal only those cases 
the specific origin of which he can prove, the frequency 
of gonorrheal lesions in women will be considerably 
understated. 

Sanger states that in about one-eighth of all gyneco- 
logical diseases gonorrhea is the underlying cause. Tay- 
lor, viewing the condition from the side of the venereal 
specialist, says that this statement is conservative and 
probably nearly correct. 

It must be borne in mind that gonorrhea is sometimes, 
caused in other ways than by coitus. This is seen in the 
epidemics of gonorrhea that occur in children. It is with- 
out doubt sometimes caused by the use of an infected 
vaginal syringe. Cases of rectal gonorrhea are not infre- 
quently thus produced. 

Gonorrhea in women may attack any part of the gen- 
ito-urinary tract. It rarely attacks a number of struc- 
tures at one time, but it usually becomes localized in one 



GONORRHEA IN WOMEN. 45 1 

or two parts, such as the urethra, the glands of the ves- 
tibule, the vulvo-vaginal glands, the vaginal fornices, or 
the cervix uteri, and runs a subacute course, and may re- 
main quiescent for a long period. It may in time dis- 
appear spontaneously, or it may be excited into activity 
by a variety of causes, such as traumatism, unusual 
coitus, labor, or miscarriage. The parts of the genito- 
urinary apparatus that are covered by pavement epithe- 
lium are much more resistant to the gonococcus than are 
the parts covered with cylindrical epithelium. For this 
reason the external genital surface and the vagina of the 
woman, and the vaginal aspect of the cervix, are often 
exempt when other less resistant structures are attacked. 

Gonorrhea attacks the different parts in the following 
order of frequency: the urethra, the cervix uteri, the 
vulva, and the vagina. 

* Gonorrhea of the urethra is the most common form of 
the disease. The great majority of the cases of urethritis 
in women are of gonorrheal origin. Whenever there is 
a purulent or muco-purulent discharge from the urethra 
gonorrhea should be suspected, whether or not the gono- 
coccus is found in it. 

The disease may linger in the mucous glands found 
near the external meatus and in Skene's glands for a long 
time. The symptoms of this condition have already been 
considered. The disease may present all the phenomena 
of acute urethritis in the male, or it may be subacute 
from the beginning. 

Gonorrhea of the cervix uteri occurs next in frequency. 
As far as the few accurate observations that have been 
made teach us anything, gonorrhea of the cervix is but 
little less frequent than gonorrhea of the urethra. The 
disease may exist in conjunction with gonorrhea of some 
other part, or it may occur alone. The infection takes 
place directly from the discharge of the penis which 
comes in contact with the external os. Gonorrhea of 
the cervix usually begins in a subacute or an insidious 
manner. It is usually unattended by any general or 



452 A TEXT-BOOK OF DISEASES OF WOMEN. 

local symptoms sufficiently marked to attract attention. 
If the woman had been free from a leucorrheal discharge, 
she may observe a muco-purulent secretion caused by the 
gonorrhea. If she had a leucorrhea, the alteration in 
the character and amount of the discharge is usually 
not sufficient to attract her attention. In some cases the 
discharge becomes more purulent in character; in others 
there is no alteration perceptible to the naked eye. 

If the disease runs an acute course, the appearance of 
the cervix will be that characteristic of acute inflamma- 
tion. The vaginal cervix is congested; the external os 
is patulous and is surrounded by a red granular or eroded 
area, while from it is seen escaping a purulent discharge. 

Pelvic pain or discomfort is not usually present unless 
the body of the uterus is attacked. 

All the symptoms of gonorrheal inflammation of the 
cervix are found in simple non-specific conditions. The 
only certain diagnosis is made by means of the micro- 
scope; and even failure to find the gonococcus will not 
enable the physician to say with certainty that the dis- 
ease is not of gonorrheal origin. 'The gonococcus may 
be found in any form of discharge, from the cervix, even 
that which to gross examination appears most innocent. 

Consequently, in every suspected case a microscopic 
examination should be made. 

The discharge, for examination, should be taken from 
the cavity of the cervix by means of a sterile platinum 
loop. If no gonococci are found, a strip of mucous 
membrane from the cervical canal should be removed 
with a sharp curette, and it, with the discharge that ad- 
heres to it, should be carefully examined. 

It may be advisable to examine the discharge immedi- 
ately after menstruation, A cervical discharge is always 
increased immediately before, during, and after a men- 
strual period. This is probably the reason that men are 
more liable to contract gonorrhea at that time. This fact 
is so well known that there is a widespread popular be- 
lief that gonorrhea may be acquired from coitus, during 



GONORRHEA IN WOMEN. 453 

a menstrual period, with a healthy woman. This is not 
true. A man cannot acquire gonorrhea from a woman 
unless she had been previously infected with the disease; 
otherwise a woman might develop gonorrhea in herself 
spontaneously, for her discharges come in contact with 
her own genito-urinary tract. 

The greater liability to infection at the time of men- 
struation is due to the fact that an existing pathological 
discharge is increased in amount; a subacute disease is 
rendered more active by the menstrual congestion; and 
gonococci, quiescent in the superficial cells, are more 
likely to be thrown off at this time. 

Gonorrhea of the cervix very often stops at the internal 
os. It may, however, extend to the body of the uterus 
and to the Fallopian tubes, as has already been described. 
The diagnosis of gonorrheal endometritis can be made 
only by microscopic examination of the discharge or of 
a strip of the endometrium removed with the curette. 

The gonorrheal discharge of the cervix may infect, 
secondarily, local areas of the vagina. The most usual 
position of secondary infection is the posterior vaginal 
fornix. A red eroded area, caused in this way, is often 
found. The prolonged contact of the pus produces a 
localized vaginal gonorrhea. 

Primary vaginal gonorrhea is rare in the adult woman, 
in whom there is the usual resistant power of the epithe- 
lium. The mucous membrane of the vagina becomes 
tough from coitus and childbirth, and is usually impreg- 
nable to the gonococcus. Bumm has kept gonorrheal 
pus in contact with the vaginal wall for twelve hours 
without producing any inflammatory reaction. 

In girls and in young women, in whom the mucous 
membrane of the vagina is soft and hyperemic, vaginal 
gonorrhea is more likely to occur. Iyike gonorrhea in 
other parts, the disease may be acute or chronic. It may 
involve the whole vaginal tract or it may be restricted to 
local areas. 

The disease sometimes involves only the lower portion 



454 A TEXT-BOOK OF DISEASES OF WOMEN. 

of the vagina, and is most severe on the posterior wall. 
In other cases it is limited to the posterior vaginal fornix, 
where it has a tendency to become localized and to persist. 
In the very early stage the mucous membrane is dry and 
red. It later becomes covered with a purulent or muco- 
purulent secretion of a milky color. 

If the disease is extensive, severe symptoms may be 
present. The woman will suffer with burning pain in 
the pelvis, the pain being increased by any movement. 

Acute inflammation of the vagina is usually of gonor- 
rheal origin. A thorough examination of the condition 
can be made only by placing the woman in the knee- 
chest position and by exposing the vagina by retracting 
the perineum with the Sims speculum. The whole vag- 
inal tube, especially the posterior wall near the ostium 
and the fornices, should be carefully inspected. 

Gonorrhea of the vulva may arise primarily, or it may 
be caused by infection from discharge from the vagina or 
the cervix. Like gonorrhea of the vagina, it is rare in 
the adult woman. It is usually seen in girls or in young 
women. Its occurrence in children has already been 
referred to. 

The disease may extend to the small glands of the 
vestibule and the fourchette and to Bartholini's glands; 
in these situations it may lurk for many years, forming a 
source of infection to men and a great element of danger 
to the woman. Suppuration of the glands of the vesti- 
bule may result in small urethral flstulae. 

In making an examination of the external genitals the 
parts should always be thoroughly exposed and the phy- 
sician should attempt to express the fluid from the orifices 
of the glands. Microscopic examination of the dis- 
charge should be made. 

Inflammation of any of the glands of the external gen- 
itals is usually the result of gonorrhea. 

When the physician examines a woman suspected of 
gonorrhea, she should not prepare herself beforehand by 
vaginal douches and washing the external genitals. The 



GONORRHEA IN WOMEN. 455 

urine should not have been voided for some time. Pros- 
titutes, fearing that gonorrhea will be discovered, often 
remove all discharges as much as possible before they 
submit to examination. Other women do the same from 
motives of cleanliness. As the diagnosis depends upon 
observation of the origin and character of the discharges, 
such preparation should be avoided. 

As has already been said, it may be advisable in doubt- 
ful cases to make the examination immediately after a 
menstrual period, when the discharges are more profuse 
and perhaps more virulent than at other times. The ex- 
aminer should always proceed methodically, and should 
inspect every portion of the external genitals, the vagina, 
and the cervix. The vestibule, the external meatus, the 
urethra, the fourchette, the glands of Bartholin], the 
vaginal walls, the external os, and the cervical canal 
should in turn be examined. Discharges obtained from 
these structures should be saved and submitted to micro- 
scopic examination. 

Though the gonococcus is by no means always found 
in cases the specific character of which is proved by in- 
fection of the man, yet it would escape observation much 
less often if such thorough examination were made. 

If the gonococcus is not found, the diagnosis must be 
made from the consideration of the lesions that we know 
occur but rarely except in gonorrhea. Thus, urethritis 
is a strong diagnostic point in favor of gonorrhea; so is 
inflammation of the glands of the vestibule, of the four- 
chette, and of the vulvo-vaginal glands. Vaginitis not 
caused by the degenerations of old age, by traumatism, 
or by the discharge from a cancer of the cervix or from a 
vesico-vaginal fistula is usually of gonorrheal origin. 
This is especially true of vaginitis localized in the vag- 
inal fornices. 

Gonorrhea in women should be most carefully treated 
until all signs of the disease are eradicated. The treat- 
ment has already been discussed under the consideration 
of the different structures that may be attacked. Conor- 



456 A TEXT-BOOK OF DISEASES OF WOMEN. 

rheal cervicitis and endometritis are the most difficult to 
cure, and it may be impossible to determine with cer- 
tainty that the disease has been eradicated from these 
structures. If milder measures fail, the cervical canal 
and the body of the uterus should be completely curetted, 
and the raw surface should be treated with pure carbolic 
acid. The physician should never discharge the patient 
until she is thoroughly cured. 



CHAPTER XXXIX. 
THE TECHNIQUE OF GYNECOLOGICAL OPERATIONS. 

The technique of some of the special gynecological 
operations, such as perineorrhaphy, and trachelorrhaphy, 
has already been considered in discussing the treatment 
of the conditions in which such operations are applicable. 
The general and local preparation of the patient, the 
instruments, the dressings, etc., and the technique of the 
general operations of gynecology that are applicable to a 
variety of different pathological conditions, such as ooph- 
orectomy and hysterectomy, now demand consideration. 
The general rules of asepsis that are followed in gyne- 
cological operations are the same as those that should be 
observed in all surgical operations. And although every 
surgeon should strive to attain perfect asepsis in all ope- 
rations, yet it is of especial importance for the gynecolo- 
gist to do so, for he, more often than all others, invades 
the peritoneal cavity. Of the various structures of the 
body, the peritoneum is one of the most susceptible to 
septic influences; and septic infection of the peritoneum, 
unlike infection of other structures, implies not merely 
a local disturbance and delay of healing, but general 
sepsis and death. 

Moreover, the gynecologist, operating in the perito- 
neum, cannot correct any imperfection in his aseptic 
technique by the use of antiseptic solutions, as can be 
done in other operations of general surgery. Such anti- 
septic solutions, if of sufficient strength to be of any value 
as germicides, are very dangerous in the peritoneum. 
They may produce fatal poisoning from absorption 
through the peritoneum ; they destroy the delicate peri- 
toneal surface, and thus diminish the very useful power 

457 



458 A TEXT-BOOK OF DISEASES OF WOMEN. 

of the peritoneum to absorb blood and serum after the 
operation; they cause intestinal and other adhesions; and 
they so impair the integrity of the intestinal walls that 
septic organisms may be enabled to pass through and 
infect the general peritoneum. 

The gynecologist, thus debarred from the use of anti- 
septics during a peritoneal operation, must rely altogether 
upon the perfection of his aseptic technique. 

It must not be forgotten that the danger of peritoneal 
infection, though very much less in the minor gyneco- 
logical operations on the perineum and the cervix, is yet 
never altogether absent. The whole genital tract of 
women communicates directly with the peritoneum, and 
infection at any point may extend and cause fatal peri- 
toneal sepsis. 

The danger increases with the proximity of the in- 
fected point to the peritoneum. The danger of salpin- 
gitis and peritonitis from trivial intra-uterine manipula- 
tions not performed aseptically, such as the passage of a 
dirty sound, has already been referred to. Fatal perito- 
nitis has followed trachelorrhaphy. * 

In the various plastic operations of gynecology disas- 
trous results are, of course, not so likely to occur from 
imperfect asepsis as in those operations that involve 
opening the peritoneum. In some of these operations, 
such as closure of a vesico-vaginal or a recto-vaginal fis- 
tula, it is impossible to obtain perfect asepsis. 

In minor gynecological operations, however, we may 
use antiseptic solutions which are inadmissible within 
the peritoneum; and the vascularity of the genital tract 
is so great that healing is usually rapid and perfect even 
with very imperfect asepsis. This fact, however, should 
never justify carelessness on the part of the physician. 
In every surgical procedure, however trivial, the strictest 
asepsis should always be observed. The practice avoids, 
at any rate, a minimum danger; it is a useful training 
for the physician; and it sets a valuable example to the 
assistants and nurses. No part of the technique should 



TECHNIQUE OF GYNECOLOGICAL OPERATIONS. 459 

be "good enough." It should be as good as it can be 
made. 

The greatest factor in the success of modern gyne- 
cology has been asepsis. The doctrine has become so 
widely spread that the technique, and consequently the 
results, of careless operators of the present day are much 
better than those of the best operators before the days of 
Iyisterism. 

This is not said to justify carelessness. No woman 
should at operation be exposed to any dangers not in- 
separable from her condition. The assistants and the 
nurses should be especially made to feel the responsibility 
of their positions. A careless nurse or assistant may in- 
troduce sepsis and cause death after the most skilfully 
performed operation. Unfortunately, there is not a dis- 
tinct realization of this fact. An assistant, though con- 
scious of some carelessness of his own, usually beguiles 
himself with the belief that death was due to some other 
cause. If there were a distinct realization of personal 
responsibility among all concerned at an operation, death 
from infection through carelessness would be avoided as 
are other kinds of manslaughter. Unless a surgeon 
knows that he can furnish the proper aseptic conditions, 
he has no right to advise a patient to submit to operation 
unless the disease is such that operation is demanded 
under any circumstances. 

At the present day the gynecologist advises a woman 
to submit to a serious — potentially fatal — operation, like 
celiotomy, for the relief of many conditions which cause 
suffering, but which do not cause death. He does this 
conscientiously, because he knows that if the operation 
is properly performed the danger to life is very small. 
If he is not certain that the proper operative conditions 
will be at hand, he cannot conscientiously give this ad- 
vice, and he had better follow some palliative treatment. 

Operations are always better done in a well-equipped 
operating-room than in a private house. In the opera- 
ting-room we have better asepsis, better light and me- 



460 A TEXT-BOOK OF DISEASES OF WOMEN. 

chanical appliances, better discipline of assistants and 
nurses, and greater opportunity of successfully dealing 
with unexpected complications. 

In an operation which is performed in a private house 
something is always used which is more or less of a 
makeshift; and makeshifts should not be used in surgery, 
especially in abdominal surgery. If we hope to obtain 
perfect results, we must insist upon perfect surroundings 
and appliances. Continuous success is the result of 
scientific accuracy and attention to detail. I say con- 
tinuous success, because this is the only test of good 
surgery. We should not be misled by occasional bril- 
liant results obtained under imperfect conditions. In 
such circumstances the operator admits to himself that 
his patient was lucky. The element of luck should 
be entirely eliminated. Nothing should be trusted to 
luck. 

Fortunately, most of the operations of gynecology are 
performed for conditions of such a character that there is 
no demand for instant operation. The woman can usu- 
ally wait until suitable conditions* are furnished. In 
cases of emergency the surgeon can only do his best 
under the existing circumstances, not his best under the 
best circumstances. 

It cannot be denied that good results, as far as mortal- 
ity is concerned, are obtained in abdominal operations in 
private houses. The mortality, however, for a long 
series of cases of all kinds is greater than that obtained 
in well-equipped hospitals by operators of equal ability. 
The number of incomplete and imperfectly performed 
operations is much greater in private houses than in the 
hospital, for the operator with imperfect surroundings 
fears to deal radically with some unexpected conditions 
which he meets, and is satisfied if the woman's life is 
saved, though she be not perfectly cured. 

It is not necessary to dwell upon the need of proper 
training of the operator himself in abdominal surgery. 
The minor gynecological operations may be performed 



TECHNIQUE OF GYNECOLOGICAL OPERATIONS. 461 

by any one who is familiar with the ordinary principles 
of surgery and who understands the special technique of 
the operation. There is no fear of unexpected complica- 
tions in such operations. Rapidity of work is not essen- 
tial, as in abdominal surgery, and the operator may study 
the condition as he proceeds; moreover, errors arising 
from inexperience or ignorance are not attended by fatal 
results. 

In abdominal surgery, however, the operator should be 
specially trained for the work. Except in cases of 
emergency, he should not perform these operations un- 
less he expects to do so continuously. He should be 
trained by work upon the cadaver and the lower animals 
and by watching and assisting experienced operators. 
He should be prepared to deal, without hesitation, with 
every pathological condition that may be met with in 
the abdomen; a glance at works on abdominal surgery 
will show how numerous such conditions are. 

A few successes in simple cases in the hands of an in- 
competent operator will lure him on with false confidence 
until he finally meets a condition with which he is unable 
to cope. Either the patient dies as a result, or, if the op- 
erator be conservative, the abdomen is closed over an in- 
complete operation. 

The directions which are about to be given apply espe- 
cially to those operations in which the peritoneal cavity 
is entered. They may be modified in obvious particulars 
in case a minor operation is to be performed upon the 
vagina or the uterus. In such cases special abdominal 
cleansing is unnecessary and complete evacuation of the 
intestinal tract is not so important. 

The technique described is that which is followed by the 
writer. Various equally good modifications are employed 
by other operators. It seems best, however, to give but 
one rigid method which experience has proved success- 
ful. The experienced operator is able to change it ac- 
cording to his individual preferences. 

Operating-room. — The operating-room should be 



462 A TEXT-BOOK OF DISEASES OF WOMEN. 

well lighted from the top and at least one side. If a good 
natural light cannot be secured, an electric drop-light 
will be found very convenient. For work deep in the 
pelvis or the abdomen a good light is essential. If neces- 
sary, light may be directed to the desired point by means 
of the ordinary head-mirror. 

The floor, walls, and ceiling of -the room should be of 
some non-absorbing material. There should be in the 
room no appliances whatever that are not essential for the 
performance of the operation. 

The interior of the room should be wiped throughout 
with a mop or with wet cloths, or, still better, flushed 
with the hose, in order to remove and lay all dust. The 
room may be wiped throughout with a solution of bi- 
chlorid of mercury (1 : 2000). At the Gynecean Hos- 
pital the operating-rooms are disinfected once a week 
with formaldehyd gas. 

The temperature of the room should be not less than 
75 F. Shock from bodily loss of heat and exposure of 
the peritoneum is diminished if the atmosphere of the 
room is at an elevated temperature? 

Apparatus. — All apparatus, such as basins, tables, 
etc. , should be of such a character that it may be steril- 
ized by boiling or by washing with a solution of bichloride 
of mercury (1 : 1000). Glass-top tables with painted or 
nickel-plated frames are preferable. The operating-table 
should be so arranged that the patient may be placed in 
the Trendelenburg position (Fig. 193). This position 
permits the intestines to gravitate out of the pelvis, and 
is very useful in many operations. There are a great 
variety of tables in use. Before the Trendelenburg pos- 
ture was introduced the writer used for several years a 
plain hard-wood plank supported by two wooden horses. 
The Boldt table is very convenient. With it there is no 
necessity for a rubber pad for catching fluids. It is ap- 
plicable for all gynecological operations. Some operators 
are in the habit of dressing the operating table by placing 
on it a blanket and sheet. This is unnecessary, unless 
the patient is in such a condition of collapse that it is 



TECHNIQUE OF GYNECOLOGICAL OPERATIONS. 463 

essential to preserve all bodily heat The blanket usu- 
ally becomes saturated with fluids and serves no good 
purpose. 

The number and arrangement of the basins, tables, 
stands, etc. used in an abdominal operation are shown in 
Fig. 194. 

The basins are best sterilized by boiling, or by wash- 
ing with scalding water (inside and outside) and a solu- 
tion of bichloride of mercury (1 : 1000). 

The tables and stands are sterilized by washing with 
the bichloride solution. If wooden-top tables are used, 




Fig. 193. — Trendelenburg position. 



they should be covered with a towel wrung out of a 
1 : 1000 bichloride solution. 

Operator, Assistants, Nurses. — Usually one assist- 
ant, who stands opposite the operator, and two nurses, are 
sufficient. A second assistant, standing beside the ope- 
rator, is useful to thread needles and to hand instruments 
and ligatures. The operator, assistants, and nurses 
should possess such general cleanliness as follows a 
morning bath. They should not attend any patients 
suffering with a septic or infectious condition upon the 
day of the operation. If they have done so upon the 
previous day, they should subsequently take a general 



464 A TEXT-BOOK OF DISEASES OF WOMEN, 




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TECHNIQUE OF GYNECOLOGICAL OPERATIONS. 465 

bath and change all clothing. Care in this respect is 
especially desirable on the part of the nurses, whose long 
hair prevents easy cleansing of the head. 

The operator and assistants should wear sterilized outer 
clothes — cotton shirt and duck trousers. A large steril- 
ized apron put on immediately before the operation is an 
additional protection. The nurses should wear large 
sterilized aprons over freshly washed, if not sterilized, 
dresses. 

The hands and forearms of the operator, assistants, and 
nurses should be bare and especially sterilized. The 
finger-nails should be short, rounded, and smooth. A 
long nail is difficult to clean, and in the case of the ope- 
rator is dangerous, as it may lacerate important structures 
in the process of enucleation of a tumor. Enucleation 
of adherent growths is best done with the blunt finger, 
which passes along the planes of separation. The sharp 
nail may perforate an intestine or lacerate a blood-vessel, 
instead of pushing it aside. 

The nails, fingers, hands, forearms, and lower part of 
the upper arms should be thoroughly scrubbed with fre- 
quently changed hot water and soap (preferably soft soap) 
and a large stiff nail-brush. The process should not be 
done hastily or but once. The soap should be repeatedly 
washed off and renewed. Five minutes, at least, should be 
devoted to the scrubbing. The hands and arms should then 
be similarly scrubbed with alcohol, and finally scrubbed 
with a solution of bichloride of mercury 1 : 1000. Im- 
mediately before proceeding with the operation the hands 
and arms should be rinsed in sterile water. 

There should be a nail-brush for each solution used. 
The brushes should be clean and sterilized by boiling 
or by placing in the steam sterilizer. 

After sterilizing the hands, the operator, the assistants, 
and nurses should touch nothing which is not sterile. If 
they are obliged to do so, the hands should be again 
washed. 

Rubber gloves, such as are used in general surgery, are 
so 



466 A TEXT-BOOK OF DISEASES OF WOMEN. 

very useful in the operations of gynecology. They may 
be worn to protect the patient in case the operator or the 
assistants are not certain of the sterility of their hands, 
or to protect the operator when working upon a septic 
patient. Rubber gloves should be sterilized in the steam 
sterilizer. 

Sterilisation of Dressings, Towels, etc.— The ope- 
rating-cloths, aprons, sheets, towels, dressings, gauze 
pads, etc. are most conveniently sterilized by steam heat. 
The temperature should be at least ioo° C. (212 F.). 
The dressings and bandages should not be too tightly 
packed, so that all parts may be exposed to the same 
temperature. 

Several kinds of steam sterilizers have been introduced. 
The most easily obtained is the Arnold sterilizer. An 
apparatus like the Sprague sterilizer, in which the steam 
is superheated, is preferable, but, as it is not portable, it 
is adapted only for hospital use. 

The dressings should be maintained at the elevated 
temperature for an hour or more. Although this method 
secures very good sterilization, yet there are certain spores 
which resist such elevated temperature even after a two 
hours' exposure. The method of fractional or discon- 
tinuotis sterilization has therefore been introduced. Two 
or three successive sterilizations are practised at inter- 
vals of twenty-four hours. Spores which at first escape 
destruction will- have developed into vegetative forms in 
the intervals, and are destroyed by the final sterilizations. 

At the Gynecean Hospital all dressings are sterilized 
for three consecutive days for two hours each day. The 
dressings, towels, etc., after sterilization, should be pre- 
served in sterile glass jars or other sterile receptacle. 

Sterilisation of Instruments. — Instruments, drain- 
age-tubes, catheters, and any rubber appliance may be 
sterilized by boiling in water for fifteen to thirty min- 
utes. A dilute solution (1 per cent.) of carbonate of 
soda is preferable, as the instruments are not so easily 
rusted, and this solution, when boiling, has greater germi- 
cidal qualities than plain water. 



TECHNIQUE OF GYNECOLOGICAL OPERATIONS. 467 

Very convenient instrument-sterilizers are made, in 
which the instruments are contained in a tray that may 
be lifted out and placed in the receptacle for containing 
the instruments during the operation. This receptacle or 
pan should itself be sterilized, and should contain sterile 
water, or preferably the sterile solution of bicarbonate of 
soda, in sufficient quantity to cover the instruments. 

It is very convenient to keep on hand a saturated solu- 
tion of carbonate of soda, sterilized by boiling, a small 
quantity of which may be added to the water in the in- 
strument-tray. Rusting of instruments is diminished by 
this means. 

Appliances that are injured by moist heat or by steam 
may be sterilized by thorough washing and soaking in a 
solution of bichloride of mercury (1 : 1000). It is useful 
to keep a large vessel of such a solution on hand, in 
which apparatus that is not injured by the bichloride 
may be placed. 

The Water. — The water used during the operation, 
for washing the wound, the abdominal cavity, the 
sponges, and the hands of the operator and assistants, 
should be sterilized by boiling or by distillation. The 
water should be boiled for two hours a day on two con- 
secutive days, or it should be boiled under pressure as in 
some of the modern water-sterilizers. If the water con- 
tain a perceptible sediment, it should first be filtered. 

Very convenient water-sterilizers are made, from which 
the water may be drawn of any desired temperature, after 
having been both filtered and sterilized by heat. There 
should always be a large quantity of sterile hot water at 
hand. Water below the temperature of the body should 
not be introduced in the peritoneal cavity, and pads 
brought in contact with the intestines should be wrung 
out of hot water. 

About fifteen gallons of sterile water are usually re- 
quired in an abdominal operation. 

The water should be preserved in sterile pitchers, 
basins, or other receptacles. 



468 A TEXT-BOOK OF DISEASES OF WOMEN. 

Glass flasks are very convenient for containing the water 
with which the abdomen or pelvis may be washed out. 
The water may be poured directly into the abdomen from 
the flask. The flask should be plugged with non-absorb- 
ent cotton to prevent the entrance of dust. 

Some operators prefer to use a normal salt solution 
(sodium chloride gr. 90 to water sxxxiiiss) for washing 
out the peritoneum. Such a solution is probably less 
irritating to the peritoneum than plain water. 

If the flasks are used for containing the water, it may 
be boiled in them, and then preserved by plugging with 
absorbent cotton until required at the operation. The 
temperature of the water used for abdominal irrigation 
should be ioo° to 115 F. 

Sponges. — In the minor operations about the vagina 
or uterus the field of operation may be kept clean by 
irrigation with sterile water or by the use of sponges. 
Small sponges in holders are commonly used. These 
sponges, after being washed free of sand and bleached if 
necessary, may be sterilized by soaking for twelve hours 
in a solution of bichloride of mercury (1 : 500). They 
should then be rinsed in warm water and preserved in a 
3 per cent, watery solution of carbolic acid, which should 
be changed every week. 

Artificial sponges, or gauze sponges, are the most con- 
venient in abdominal surgery. They are cheap, and may 
be destroyed after each operation, and they are very 
easily and certainly sterilized in the steam sterilizer. 
Good marine sponges are so expensive that but few ope- 
rators destroy them after they have been once used. The 
cleansing and sterilization of such sponges are tedious 
and uncertain. The gauze sponges answer even' pur- 
pose. 

The gauze sponges may be made of various sizes by 
sewing together about eighteen layers of plain absorbent 
gauze. The edges of the gauze should be folded in and 
hemmed to prevent the escape of loose threads in the 



TECHNIQUE OF GYNECOLOGICAL OPERATIONS. 469 

peritoneum. Some operators use sponges made by wrap- 
ping absorbent cotton somewhat loosely in gauze. 

The number of sponges used should always be recorded 
before the operation. It is advisable to preserve the 
sponges in sets always of the same number, so that in 
every case the operator knows that this number, or some 
multiple of this number, of sponges has been used. The 
writer uses such sets of seven gauze sponges of the fol- 
lowing sizes: one sponge 3 by 3 inches; one sponge 10 
by 7 inches; five sponges 5 by 5 inches. Usually one 
such set of sponges is enough for an abdominal opera- 
tion. In some cases, however, the first set of sponges 
may become soiled by the discharge from an abscess or a 
suppurating tumor, and it is advisable to discard these 
sponges and to complete the operation with a second 
clean set. 

The number of sponges should never be altered during 
an operation by cutting one in two. 

Sponges should never be removed from the operating- 
room until the abdomen has been closed and the sponges 
have been counted. If a sponge falls on the floor or in 
the vessel to receive slops, it should be put aside until 
the final counting is completed. 

When a set of sponges is used, they should always be 
carefully counted as they are placed in the basin, for the 
nurse who prepared and put up the set may have care- 
lessly miscounted them. 

Accuracy in regard to the sponges is of the greatest 
importance. There are a number of recorded cases, and 
many unrecorded, in which sponges have been left in 
the abdomen. This accident is usually fatal, though 
there are several cases on record in which the sponge has 
made its way, by ulceration, into the intestine, and has 
been discharged from the anus, or has been removed by 
subsequent incision through the abdominal wall. 

Discipline of the Operating-room. — The discipline 
of the operating-room should be most rigid. Perfect 
personal asepsis can be obtained only by continuous 



470 A TEXT-BOOK OF DISEASES OF WOMEN. 

watching and criticism. The work should be syste- 
matically divided among the assistants and nurses, and 
each should attend strictly to his or her own department, 
and to nothing else. 

The first assistant should assist the operator with 
sponges, etc. The second assistant should attend to the 
instruments, ligatures, and sutures. The first nurse 
should wash the sponges and place them in a basin of 
sterile water beside the first assistant. She should also 
attend to the towels and dressings. The second nurse, 
under direction of the first, should change soiled water 
in the sponge- and hand-basins, etc. 

No one should pick up anything that may have been 
dropped upon the floor, and no one, unless it is abso- 
lutely necessary, should touch anything that has not 
been sterilized. 

Anesthesia. — With the exception of the operator, the 
anesthetizer is the most important person at an abdom- 
inal operation. A careful, experienced anesthetizer is 
desirable in all operations, but especially so in an abdom- 
inal operation. Much more depends upon him than upon 
the assistant. The custom of trusting the anesthesia to 
the least experienced man is reprehensible. Many fatal 
cases after celiotomy may be attributed directly to the 
anesthesia. 

Every operator of experience has observed the differ- 
ence in reaction between those patients who have been 
carefully anesthetized and those who have been improp- 
erly anesthetized. In a serious case attended by unavoid- 
able shock the superadded depression of ether-poisoning 
maybe enough to cause a fatal result. 

ilfee operator should have nothing to do with the anes- 
thesia, and it should not be necessary for him to watch it. 
The anesthetizer should make a careful examination of 
the heart, and should be provided with a hypodermic 
syringe and the necessary stimulants, which he should 
use at his own discretion. 

He should, of course, use the minimum amount of 



TECHNIQUE OF GYNECOLOGICAL OPERATIONS. 471 

ether. He should be familiar with the steps of the ope- 
ration, and he should so regulate the anesthesia that the 
operator will not be impeded by the straining or struggles 
of the patient at critical moments. 

Preparation of the Patient. — It is always desirable, 
when possible, to have the patient under observation for 
several days before operation. As I have already said, a 
more accurate diagnosis may be made by repeated exam- 
inations, and opportunity is afforded for the administra- 
tion of medicines to improve the general condition. A 
weak woman about to submit to a serious operation is 
benefited by the administration of 2V grain of strychnine 
three times a day, for several days before the operation. 

During this period the patient should receive a daily 
bath, a laxative when necessary to produce a daily move- 
ment, and a vaginal douche of one gallon of hot water 
every morning and evening. 

The special preparation of the patient is directed to 
sterilizing the abdominal surface, the external genitals, 
and the vagina, and to emptying the gastro-intestinal 
tract. This preparation should begin twenty-four hours 
before the operation. During this time it is best to con- 
fine the patient to bed. 

Thorough evacuation of the intestinal tract is very de- 
sirable in abdominal surgery. When the intestines are 
empty and collapsed, the various intra-abdominal manip- 
ulations are most easily performed. If the intestine is 
injured and it becomes necessary to repair it, or if any 
other intestinal operation is required, it may be performed 
most easily and with the greatest cleanliness if the gut is 
empty. 

Though it is impossible to sterilize the intestinal tract, 
yet we most nearly approach the condition of sterilization 
by thorough evacuation of the bowels. 

Twenty-four hours before the operation purgation 
should be begun by the administration of 1 dram oi 
Rochelle salts, dissolved in half a tumblerful of water 
or soda-water, every hour until the bowels begin to move 



472 A TEXT-BOOK OF DISEASES OF WOMEN. 

freely. Five or six doses are usually sufficient. The 
lower bowel should finally be emptied thoroughly by an 
enema of soap and water administered three or four hours 
before operation. During the twenty-four hours preced- 
ing operation the diet should consist of light, easily 
digested, concentrated nourishment, such as milk, butter- 
milk, soft-boiled eggs, rare beef, soups, beef-tea, coffee, 
tea, and whiskey if necessary. 

Unless the patient is very weak, no food should be 
given on the morning of the operation. If her condi- 
tion does not warrant such, abstinence, she may have a 
glass of milk, buttermilk, coffee, or milk-punch. Such 
food is required if the operation is performed late in the 
day. 

In very feeble patients a nutrient enema may be ad- 
ministered about two hours before the operation. 

A hypodermic injection of ^V grain of strychnine is 
often useful upon the morning of the operation when the 
patient is in poor condition. 

Preparation of the External Genitals and Vagina. — 
The pubis and the external genitals should be shaved. 
The woman should be drawn down to the edge of the bed, 
and the anus, the external genitals, and the vagina 
should be scrubbed with green soap. The vagina should 
be washed throughout. The nurse may do this by in- 
serting one or two fingers, or she may retract the peri- 
neum with the Sims speculum, and scrub the vagina, 
the fornices, and the vaginal cervix with cotton held in 
forceps. 

The scrubbing; should be followed bv a vaginal douche 
of a gallon of hot water to wash out the soap, and then 
by a douche of two quarts of bichloride solution (i : 2000). 
One hour before operation the vaginal douche of bi- 
chloride should be repeated, and the nurse should intro- 
duce in the vagina as far as the cervix a light vaginal 
tampon of gauze wet with the bichlorid solution. In 
every abdominal operation on women it is desirable that 
the external genitals and the vagina should be clean. It 



TECHNIQUE OF GYNECOLOGICAL OPERATIONS. 473 

mav be necessary to pass the catheter or to perform some 
vaginal manipulation, or the vagina may be opened dur- 
ing the operation. 

If the vagina is small or virginal, or if the woman is 
nervous, the nurse may be unable to perform the method 
of cleansing just described; and it is then necessary for 
the operator or the assistant to clean the vagina after the 
woman is anesthetized. Such cleansing should always 
be performed, in addition to the cleansing by the nurse, 
whenever a vaginal operation is performed or it is ex- 
pected that the vagina will be opened from above. 
Thorough vaginal sterilization is most easily accom- 
plished when the patient is under the influence of ether, 
as the perineum is easily retracted and the vagina be- 
comes more patulous. The woman should be placed in 
the lithotomy position, and the washing should be per- 
formed with two lingers or with a soft brush like a 
jeweller's brush, or with cotton in forceps. If neces- 
sary, the perineum should be retracted with the specu- 
lum. Green soap should be used, and the vaginal walls, 
the fornices, and the cervix should be thoroughly scrub- 
bed. The soap should then be carefully washed out, and 
the scrubbing should be repeated with bichloride-of-mer- 
cury solution (1 : 2000). 

The cleansing of the external genitals and the vagina 
is best done by the nurse after the final movement of the 
bowels and immediately before the woman has her. gen- 
eral bath. 

Sterilisation of the Abdomen. — The patient should have 
a warm bath from head to feet upon the morning of the 
operation. The abdomen, from the ensiform cartilage 
to the pubis, should be scrubbed with a nail-brush. 
Special care should be devoted to cleansing the umbili- 
cus. After this bath the patient should be dressed in a 
clean flannel undershirt and night-gown and should be 
placed in a clean bed. 

The nurse should then wash the abdomen, from the 
ensiform cartilage to the pubis and from flank to flank, 



474 A TEXT-BOOK OF DISEASES OF WOMEN. 

and the upper third of the anterior aspect of the thighs, 
first with turpentine, second with green soap, and finally 
with ether, devoting special care to the umbilicus. The 
abdomen should then be covered with a large wet bi- 
chloride dressing (i : 2000), which should not be removed 
until the patient is upon the operating-table. A towel 




Fig. 195. — Tait's hemostatic forceps. 

wrung out of the bichloride solution and held in place by 
a bandage or binder will answer the purpose. A second 
cleansing of the abdomen by the operator or the assistant 
should be done after the patient is upon the table. The 
surface should be washed with green soap and sterile 




Fig. 196. — Spencer Wells' forceps. 



water, then with ether, and finally with the solution of 
bichloride of mercury. The washing should not be re- 
stricted to the central abdomen, but should extend over 
the upper parts of the thighs and the flanks, which may 
be exposed during the operation. 

The bladder should be emptied by the catheter im- 



TECHNIQUE OF GYNECOLOGICAL OPERATIONS. 475 

mediately before the patient is placed upon the operat- 
ing-table. 

The patient should be placed upon the operating-table 
by clean nurses or assistants. 

The legs should be strapped to the table. The hands 
should be held out of the way by the anesthetizer. They 
may be retained very well by a safety-pin passed through 
the lower sleeve and the shoulder of the night-gown or 
the pillow-case. 

The undershirt and night-gown should be drawn well 
up behind, to prevent wetting. If the clothes become 
wet, they should be changed immediately after operation. 

The legs and the chest should be covered with clean 
blankets. The field of operation should be surrounded by 
sterilized towels. One large towel with a hole of suitable 
size in the center is convenient. A pocket may be made 
immediately below the hole, to retain the instruments 
when the Trendelenburg position is employed. 

Instruments. — The number and the variety of instru- 
ments used by the gynecologist in abdominal operations 



Fig. 197. — Knife. 

depend a good deal upon the taste of the individual op- 
erator. The list given here comprises all the instruments 
that are found useful by the writer in abdominal work: 

Small hemostatic forceps (Fig. 195) 12 

Medium-sized forceps 2 

Large forceps (Fig. 196) 4 

Knife (Fig. 197) 1 

Scissors — two pairs of long scissors, one straight and 

one curved on the flat. 

Pedicle-needles (Fig. 198^ - 

Cyst-trocars (Figs. 199 and 200) 2 

Straight, spear-pointed needles, 2>£ inches in length, 

for closing the abdominal incision 03- the mass-suture. 



47^ A TEXT-BOOK OF DISEASES OF WOMEN. 

Curved needles for suturing within the abdomen. 
Fine straight and curved needles for the repair of in- 
testinal injuries. 
Large curved needles for catgut, etc. 

Abdominal retractors (blunt) 2 

Needle-holder (Fig. 201) 1 

Ivong dressing-forceps 2 

Three sizes of twisted silk are used for suture and liga- 
ture: heavy silk for ligature of the large arteries; medium 
silk for ligature of smaller vessels and for various sutur- 
ing in the abdomen ; fine silk for peritoneal and intestinal 
suture. 




Fig. 198. — Pedicle-needle. 

The silk should be as small as is consistent with secure 
ligature. The heavy silk is necessary for the ligature of 
pedicles in which a large amount of surrounding tissue 
is included with the artery. 




Fig. 199. — Small curved trocar. 

The silk is rolled on glass spools or on cores of gauze, 
contained in glass tubes plugged with cotton, and is then 
sterilized in the steam sterilizer by fractional steriliza- 
tion. It is advisable always to use, for heavy ligature, 
silk of a uniform size, because the operator becomes 
accustomed to the strength of the silk and knows just 
how much strain it will bear. Silkworm-gut is the best 
material to use for suture of the abdominal incision in 



TECHNIQUE OF GYNECOLOGICAL OPERATIONS. 477 

or interrupted mass- 



through-and-through 



case the 

suture is employed. 

The silkworm-gut should be of the heaviest and the 
longest size. It may be sterilized by boiling with the 
instruments before the operation. 




Fig. 200. — Large cyst-trocar. 

Catgut is sometimes employed for ligature and suture. 
The difficulty of securing certain sterilization makes it 
advisable to avoid using this material within the peri- 
toneal cavity. Sterilized silk is so certainly absorbed in 
all cases and is so easily employed that the writer has 
altogether given up the use of catgut within the peri- 
toneum. It is useful as a buried suture for the muscle 
and fascia of the abdominal wall. Silk is not so cer- 
tainly absorbed in this position, and if the catgut should 
happen to be imperfectly sterilized, no worse result than 
suppuration of the incision will occur. 




Fig. 201. — Reiner's needle-holder. 



Various methods of sterilizing catgut have been intro- 
duced. The writer uses the following method, which 
bacteriological experiments and clinical experience have 
shown to be good: The catgut is soaked in juniper oil 
for one week. The oil is then washed out with ether 
and the catgut is soaked in ether for forty-eight hours. 



478 A TEXT-BOOK OF DISEASES OF WOMEN. 

The gut is then rolled on glass spools and is placed in a 
glass jar containing pure alcohol. The alcohol is boiled 
in the jar for an hour at a time on several successive days. 
The gut is used directly from this jar, and is always 
boiled in the alcohol for an hour before each operation. 
In this way, if a considerable amount of gut is prepared 
at one time, it is subjected to many boilings before it is 
used up. The alcohol is boiled by placing the glass jar 
in a vessel of hot water. 

The following methods of sterilizing catgut are also 
good: 

The Claudiits or Iodin Method for the Sterilization of 
Catgut. — Cut the catgut into the desired lengths and wind 
on glass slides or spools. Place in a wide-mouth jar with 
a glass stopper containing a solution composed of iodin 
and potassium iodide, each one part, and distilled water 
ioo parts. In making this solution the iodin and potas- 
sium iodide should first be pulverized in a mortar, the dis- 
tilled water should be added, and stirred with the pestle 
until solution is complete. 

At the end of eight days the catgut is sterile and ready 
for use. It may be kept indefinitely in the solution with- 
out deterioration. Before using take the catgut from the 
jar with sterile forceps and rinse in sterile water. 

The Cumol Method for the Sterilisation of Catgut, em- 
ployed at the fohns Hopkins Hospital. — i. Cut the catgut 
into the desired lengths, and roll 12 strands in a figure- 
of-8 form, so that it may be slipped into a large test-tube. 

2. Bring the catgut gradually up to a temperature of 
8o° C, and hold it at this point for one hour. 

3. Place the catgut in cumol, which must not be above 
a temperature of ioo° C, raise it to 165 C, and hold it 
at this point for one hour. 

4. Pour off the cumol, and either allow the heat of the 
sand-bath to dry the catgut, or transfer it to a hot-air 
oven, at a temperature of ioo° C. for two hours. 

5. Transfer the rings with sterile forceps to test-tubes 
previously sterilized as in the laboratory. 



TECHNIQUE OF GYNECOLOGICAL OPERATIONS. 479 

The cleanest specimens of the crude catgut should be 
obtained for surgical purposes. There is no doubt that 
some specimens of crude catgut are more difficult to 
sterilize than others. A special apparatus has been in- 
troduced for sterilizing catgut which renders the process 
safe and certain. 

The writer uses catgut only for suture of the abdom- 
inal fascia and muscles. Large-sized gut is employed. 

The Dressing.— The dressing of the abdominal wound 
consists of ten or twelve layers of sterilized gauze, cov- 
ered by a large sterilized abdominal pad about 1 inch 
thick, 13 inches long, and 9 inches broad. The pad is 
made of absorbent cotton enclosed in a layer of gauze. 
The dressing is retained in place by a six-tailed sterilized 
abdominal binder of flannel. 

If no drainage through the abdominal incision is em- 
ployed, the use of celloidin with the gauze dressing is of 
advantage. It retains the dressing securely in position 
for an indefinite period, and, if used liberally, it acts as a 
splint for the abdominal wall. Either of the two follow- 
ing formulae given by Robb may be used: 

fy. Ether (Squibb' s), 

Absolute alcohol, da. ^viss; 

Of a solution made of 15 grains of 
bichloride crystals dissolved in 11 
drams of absolute alcohol, TTlxvj. 

Mix, and add of Anthony's "snowy cotton" enough 
to give the solution the consistence of simple syrup. 

^. Absolute alcohol, ^viss; 

Iodoform powder, Sxiiss; 

Mix, and add ether, 5viss. 

Mix, and add of Anthony's "snowy cotton" enough 
to give the solution the consistence of simple syrup. 

The celloidin should be poured over the edges of the 
first layers of gauze that are placed upon the wound. 



CHAPTER XL. 

THE TECHNIQUE OF GYNECOLOGICAL OPERATIONS 
(Continued). 

Abdominal Drainage. — Drainage of the peritoneum 
is accomplished by means of the glass drainage-tube (Fig. 
202), or by capillary drainage with gauze. The perito- 



Fig. 202. — Glass drainage-tube. 

neum may be drained through the abdominal incision or 
through the vagina. On account of the difficulty of 
keeping the vagina sterile, drainage through the abdom- 
inal incision is the safer method. Vaginal drainage is 
preferred when the operation is performed through the 
vagina and no abdominal incision is made, as in the ope- 
ration of vaginal hysterectomy. 

The glass drainage-tubes should be of various lengths 
— 5 to 7 inches. The outer diameter should be about }i 
or y 2 inch. The lower portion of the tube is perforated 
with small holes over a distance of about i 1 /* inches. 
Around the upper part or neck of the tube, which pro- 
trudes from the abdomen, is placed a square of rubber 
dam, such as is used by dentists, about 8 by 8 inches in 
size. The tube passes through a hole in the center of the 
rubber. The tube and the rubber dam may be sterilized 
by boiling. The tube is usually placed in the lower angle 
of the abdominal incision, and the abdominal dressing is 
split so that it may be placed around the tube. The 
bandage is applied so that the four upper tails pass above 
the tube and the two lower tails pass below it. The 
opening of the tube and the rubber dam are outside of 

480 



TECHNIQUE OF GYNECOLOGICAL OPERATIONS. 481 

the bandage. When the dressing and bandage have been 
applied, the opening of the tube is plugged with sterile 
absorbent cotton, and a handful of cotton is placed in the 
dam, which is then folded over and pinned. A sterile 
towel is placed over the dam. Some operators insert a 
cord of cotton or a few narrow strips of gauze to the 
bottom of the tube, in order to maintain a continuous 
capillary drain. 

Cleansing or emptying the drainage-tube is a procedure 
which should be very carefully attended to. Strict asep- 
sis should be observed in all the manipulations. For the 
first few hours the general peritoneum is exposed to dan- 
ger of infection every time the tube is opened. After 
the first twenty-four hours, though the danger of general 
peritoneal infection is remote or absent, yet there is 
always danger of local infection of the tube-tract. Such 
local infection may result in a persistent sinus or other 
complication. A ligature near to or in contact with the 
tube may become infected, and the sinus will remain 
open until the ligature is discharged. 

The tube may be cleaned by any careful nurse. The 
bedclothes should be drawn down to the pubis and the 
clothing should be drawn up, so that the abdomen is ex- 
posed. Sterile towels should be placed about the rubber 
dam. The hands of the nurse should be sterilized. The 
dam should be opened, the cotton should be removed, 
and the orifice of the tube exposed. The tube should 
be emptied with the long-nozzled syringe (Fig. 203), or 




Fig. 203. — Syringe for cleaning drainage-tube. 



with some other easily sterilized apparatus by which the 
fluid may be withdrawn. 

All fluid should be withdrawn from the drainage-tube. 
The dam should be carefully cleansed by wiping with 
cotton wet with the solution of bichlorid of mercury. 
A fresh cotton plug should be inserted in the tube, and 

31 



482 A TEXT-BOOK OF DISEASES OF WOMEN. 

the dam should be folded and pinned over a handful of 
cotton. The whole should then be covered with a sterile 
towel. 

The tube should be emptied or cleaned as often as it 
becomes filled. It is often necessary at first to clean it 
every fifteen, thirty, or sixty minutes. If free bleeding 
is taking place, it is most quickly arrested by frequent 
cleaning of the tube. Unless the nurse is experienced, 
the operator or assistant should watch the drainage- 
tube for the first hour after operation, in order to di- 
rect the nurse in regard to the required frequency of 
cleansing. A record should be kept of the amount of 
fluid withdrawn. 

The intervals between cleansings are gradually in- 
creased until once every six or twelve hours becomes suf- 
ficient. It is not often necessary to keep the tube in the 
abdomen longer than two or three days. 

The tube should be removed when the fluid discharged 
becomes serous in character and small in amount — about 
one dram every four or five hours. -Before removing the 
tube the flannel binder should be opened and the wound 
should be exposed. When the glass tube is withdrawn, 
it is best to replace it by a small rubber tube. This may 
be done by inserting the rubber tube to the bottom of the 
glass tube, which is then withdrawn. If we were certain 
that the tube-tract were aseptic, the introduction of the 
rubber tube would be unnecessary, and we might close 
the lower angle of the incision immediately by suture. 
This procedure, however, may be followed by fluid-accu- 
mulation and the formation of abscess in the tube- tract. 
It is therefore safest always to use the rubber tube. The 
rubber tube should be withdrawn gradually, an inch or two 
every day, so that the tract will close from the bottom. 
In order to prevent the rubber tube slipping altogether 
into the drainage-tract, it is advisable to insert a small 
safety-pin through the extra-abdominal end. The end of 
the rubber tube should be surrounded and covered by 
several layers of gauze and the abdominal pad. 

Gause- drainage. — Capillary drainage with gauze is 



TECHNIQUE OF GYNECOLOGICAL OPERATIONS. 4 8 3 

sometimes more convenient than drainage with the tube. 
A strip, about 2 inches in width, of several layers of 
gauze should be carried, from the part of the pelvis to be 
drained, out through the lower angle of the abdominal 
incision. When the sutures are introduced the lower 
angle of the incision should not be too tightly closed, 
or drainage will be impeded. The extra-abdominal end 
of the gauze drain should be surrounded and covered by 
several layers of loosely-packed gauze and by the abdom- 
inal pad and binder. Sterile cotton should be tucked 
under the binder immediately above the pubis, and, if 
necessary, around the upper and lateral margins of the 
pad. The dressing need not be disturbed for one, two, 
or three days, unless the discharge has soaked through 
the abdominal binder. 

A convenient capillary drain is made of a gauze bag 
containing several strips of gauze. 

One objection to the gauze drain is the difficulty of re- 
moval. Lymph-processes and granulations penetrate the 
interstices of the gauze, and often render its removal very 
difficult. The surgeon fears to use too much force in at- 
tempts at withdrawal, because an adherent loop of intes- 
tine or the omentum may be pulled out of place or dam- 
aged, or the lymph- wall of the drainage-tract may become 
opened and expose the general peritoneum to infection. 
To avoid this difficulty the writer has for some time em- 
ployed a drain made by surrounding the gauze bag with 
an ordinary rubber condom the end of which has been 
cut open (Fig. 204). With this arrangement the surgeon 
may feel certain that there are no adhesions except at the 
end of the drain. Such drains may be removed as easily 
as the glass tube. The condom may be sterilized by boil- 
ing. Gauze drains should be removed at the end of two 
or three days. After withdrawing the gauze it is advis- 
able to insert a small rubber tube, for reasons that have 
been mentioned in considering the use of the glass drain- 
age-tube. 

The gauze drain may be used in all cases except when 
it is necessary to drain pus or some solid material like 



484 A TEXT-BOOK OF DISEASES OF WOMEN. 

feces. In such cases the glass tube should be employed, 
either alone or surrounded by a gauze pack to protect the 
general peritoneum. 

In pelvic surgery the drain, whether glass or gauze, 
should, as a rule, be placed at the most dependent part 
of the pelvis, which is the bottom of Douglas's pouch. 




Fig. 204 — Gauze drain with rubber cover. 



It may be placed to either side of the median line in case 
the chief discharge is expected to take place from this 
position. Hemorrhage from a bleeding surface deep in 
the pelvis may often be controlled by the direct pressure 
of the end of the gauze drain placed over it. 

The drain should be introduced immediately before the 
abdominal sutures are tied. 

Indications for Drainage. — Great diversity of prac- 
tice exists among operators as to the use of drainage 
after celiotomy, and a decided change has taken place in 
regard to drainage during the past twenty years. In the 
early days of modern abdominal surgery drainage was 
used very much more than it is at present ; some of the 
best operators used it in the majority of their cases ; now 
a number of operators never use drainage after celiotomy, 
while others use it only when specially indicated. Much 
depends upon the individual methods of the operator. 
The operator who is careless in his asepsis and hemostasis 



TECHNIQUE OF GYNECOLOGICAL OPERATIONS. 485 

should use drainage oftener than he who is careful in 
these particulars. The advice, " When in doubt drain," 
is very good; but the surgeon should strive to eliminate 
the element of doubt as much as possible, and to have a 
definite reason for all his procedures. If drainage is not 
necessary, it is harmful. It necessitates more frequent 
dressings and disturbance of the patient, and it prevents 
perfect closure of the abdominal incision. 

The object of drainage is the removal from the perito- 
neum of discharges which are, or which may become, 
septic or dangerous. Such discharges are blood, pus, 
serum, cyst-contents, and ascitic fluid. 

Even though the peritoneum be dry and all bleeding 
be arrested when the operation is completed, yet it must 
be remembered that a subsequent free serous exudation 
will take place if the peritoneum has been exposed or 
subjected to chemical or mechanical irritation. 

Infection may take place from imperfect asepsis at the 
time of operation; or it may be caused by the escape into 
the peritoneum of septic material which existed in the 
abdomen before the operation; or it may occur subse- 
quently, from the passage of septic organisms from the 
interior of the intestine through the intestinal wall. 

The absorbing power of the healthy peritoneum is so 
great that a large amount of fluid (even though not abso- 
lutely sterile) may be taken up by it. Injury of the peri- 
toneum from exposure or other irritation not only in- 
creases the amount of fluid to be absorbed, but it 
diminishes the power of absorption; and injury of the 
intestinal peritoneum or of the wall of the intestine favors 
the passage of septic organisms through it. 

The operator should bear these facts in mind when he 
considers the subject of drainage. 

A certain amount of absorption of blood or other sterile 
fluid may be trusted to the peritoneum. 

It is sometimes impossible to arrest all venous oozing 
from raw surfaces, and the blood must be left for absorp- 
tion by the peritoneum, or must be carried off by drain- 



486 A TEXT-BOOK OF DISEASES OF WOMEN. 

age with the glass tube or with gauze. Drainage enables 
the operator to watch the amount of hemorrhage after 
operations, so that if excessive he may employ measures 
to check it. Drainage also acts as a hemostatic. The 
direct pressure of the gauze upon the bleeding area 
checks the hemorrhage, and the continual removal of 
blood, the promotion of dryness, and the contact of air 
through the glass tube have a decided hemostatic effect. 

Drainage, therefore, is sometimes used not only to re- 
move blood, but to aid in arresting hemorrhage. As the 
operator becomes more experienced he practises more per- 
fect hemostasis, and learns to obliterate by buried suture, 
to fold in, or to cover with peritoneum raw bleeding sur- 
faces, so that drainage as a means of hemostasis is less 
often required. If the operator fears that the peritoneum 
has become infected from imperfect asepsis at the opera- 
tion, or from the escape into it of some septic material 
like pus, he should employ drainage, especially if he 
expects much subsequent serous or bloody discharge to 
take place. 

If the intestinal wall has been extensively injured, as 
we sometimes find after an adherent intestine has been 
liberated, drainage should be employed; for septic organ- 
isms most readily pass through such an injured wall, and 
the damage may be so great that necrosis may take place, 
with the escape of intestinal contents. It must be re- 
membered that all purulent accumulations in the abdo- 
men and pelvis are not septic. Such accumulations 
were septic in the beginning, but in the majority of 
chronic cases the septic organisms have died and dis- 
appeared, and the pus is perfectly sterile and harmless to 
the peritoneum. Consequently, if an ovarian or a tubal 
abscess ruptures during removal, and the contents escape 
into the peritoneum, drainage is not necessarily required. 
For a period of three years the writer had in such 
cases immediate bacteriological examination of the pus 
made, and determined drainage from the result of 
such examination. In the majority of cases the pus was 



TECHNIQUE OF GYNECOLOGICAL OPERATIONS. 487 

sterile and drainage was not employed. It has been 
found, as would be expected, that the pus is most often 
septic in the cases of recent suppuration and in the 
chronic cases during an acute attack. Experience also 
teaches that suppurating dermoids are very likely to be 
septic. 

It will be seen from these considerations that in deter- 
mining the question of drainage much must be left to the 
judgment and the experience of the operator. 

If an aseptic operation has been performed, and there 
is no intestinal lesion and hemostasis is perfect, drainage 
is not required. This condition of things is, of course, 
most often attained by the experienced operator. If the 
operator fears septic infection for any reason, or fears that 
the hemostasis is not good, he should employ drainage. 
At the present day the decided majority of the best opera- 
tors use abdominal drainage very little. 

When general peritoneal sepsis exists before the abdo- 
men is opened, drainage is always indicated. 

Vaginal Drainage. — Drainage of the peritoneum 
through the vagina is usually accomplished by making 
an opening through Douglas's pouch into the posterior 
vaginal fornix. A rubber drainage-tube or a gauze drain 
may then be inserted. The vagina and vulva should, 
of course, have been thoroughly sterilized. The vagina 
should be lightly packed with gauze, and the vulva should 
be protected by a gauze and cotton dressing. As has 
been said, the chief objection to vaginal drainage of the 
peritoneum is the difficulty of sterilizing and maintaining 
sterile the vagina and the vulva. 

The Incision of the Abdominal Wall. — The vari- 
ous abdominal operations of gynecology are performed 
through an incision in the median line. The position of 
the incision depends upon the condition to be treated. 
The incision for performing ventro-suspeusion of the 
uterus is made near to the symphysis pubis. The incis- 
ion for the removal of a large cyst is made at a higher 
point. As a rule, the incision, about 2 or 2} 2 inches in 



488 A TEXT-BOOK OF DISEASES OF WOMEN. 

length, should be made about midway between the um- 
bilicus and the pubis, and should be extended upward or 
downward as necessary. The incision should be as small 
as the operator can conveniently work through. He 
should not hesitate to enlarge the incision to facilitate 
any manipulations. The length will depend a good deal 
upon the thickness of the abdominal walls. 

The structures that are incised are the skin, the sub- 
cutaneous fat, the parietal fascia, the linea alba or the 
edge of the rectus muscle, the subperitoneal fat, and the 
peritoneum. 

If the incision is made exactly in the median line, the 
linea alba will be divided and the sheath of the rectus 
will not be opened. This is most usual in multiparous 
women with lax abdominal walls and widely separated 
recti muscles, and in cases in which the abdomen is dis- 
tended by a tumor. If the sheath of the rectus is opened, 
the muscle will be exposed, and the linea alba should 
be sought on the side upon which the fascia fails to 
retract. 

If the linea alba cannot readily be found, the incision 
should be carried directly through the muscle. Some 
operators consider it an advantage, in obtaining subse- 
quent firm union, to expose the muscle in this way. 
When the subperitoneal fat is reached, it should be torn 
and pushed aside with the blunt closed forceps or with the 
fingers. 

The peritoneum should be caught with forceps and 
drawn forward. The assistant should catch the perito- 
neum with a second pair of forceps at a point about % or 
y 2 inch to the side of the first pair, and the small fold 
of peritoneum thus produced should be incised with the 
knife. As soon as the smallest opening is made in the 
peritoneum the air rushes in and the intestines and omen- 
tum fall back. The opening is then enlarged with the 
knife or scissors. 

The greatest care must be exercised in those cases in 
which the omentum or the intestines are adherent to the 



TECHNIQUE OF GYNECOLOGICAL OPERATIONS. 

anterior abdominal wall. The experienced operator usu- 
ally observes indications of such a condition as soon as 
he has passed through the linea alba. The tissues are 
more rigid and unyielding than normal, and the perito- 
neum cannot be readily picked up with the forceps. In 
such cases the operator should proceed very slowly, and 
if necessary should enlarge the outer incision and enter 
the peritoneum at a point above or below the area of 
adhesion. 

Exploration of the Abdomen. — Having opened the 
peritoneum, the operator should insert two fingers (the 
middle and the index finger of the left hand) and should 
carefully examine the condition to be treated. 

If necessary, he should retract the edges of the incision, 
and should place the patient in the Trendelenburg posi- 
tion, in order to make an ocular examination. 

It is always advisable to make a preliminary investiga- 
tion of this kind before proceeding with the operation. 
In this way the diagnosis will be corrected and complica- 
tions which must be treated will be determined. It may 
be found that what was thought to be a cyst is in reality 
a uterine fibroid or perhaps a normal pregnancy; or the 
surgeon may discover a hopeless condition, such as ex- 
tensive cancer or peritoneal papilloma, for which further 
operation will be useless. 

Protection of the Intestines and Omentum. — Dur- 
ing all manipulations within the abdomen the perito- 
neum, intestines, and omentum should be handled most 
gently. Injury of the peritoneum increases the danger 
of shock, sepsis, and intestinal adhesions. The intes- 
tines should never be allowed to protrude through the 
abdominal incision unless it is necessary for the perform- 
ance of the operation. Such a necessity rarely, if ever, 
arises in gynecological operations. All the intestines 
may be removed from the field of operation — the pelvis — 
by placing the woman in the Trendelenburg position. 
Protrusion of intestines through the abdominal incision 
should be prevented by using large gauze pads or sponges. 



49° A TEXT-BOOK OF DISEASES OF WOMEN. 

It is advisable always to surround the field of operation 
by a wall of gauze pads. They protect the intestines 
and prevent the escape of fluids into the upper perito- 
neum. This precaution is especially desirable when the 
Trendelenburg position is used, to prevent fluids from 
the pelvis escaping into the upper abdomen. The pads 
should be introduced after being wrung out of warm 
water, and should be replaced by fresh warm pads as soon 
as they become saturated with fluid. If they become 
soiled by pus or other septic fluid, it is safest to discard 
them for the remainder of the operation. 

Toilet of the Peritoneum. — The field of operation, 
and, if necessary, the general peritoneum, should always 
be cleaned and dried before the abdominal incision is 
closed. This is done by sponging and by irrigation with 
warm sterile water or with normal salt-solution. The 
sponging should be performed with great gentleness, to 
avoid peritoneal irritation. There are several regions 
in which fluids and blood-clots are most likely to collect, 
and which therefore demand especial inspection. 

The chief of these regions is the hollow of the sacrum, 
or Douglas's pouch. Fluids also collect on the anterior 
surface of the broad ligaments and in the renal hollows. 

If but little fluid has escaped into the abdomen, and 
the field of operation has been confined to the pelvis, we 
need look for accumulations of fluid and blood only in 
Douglas's pouch and in front of the broad ligaments. 
If the upper portion of the abdomen has been invaded, 
it is advisable to inspect the renal hollows. 

Blood-clot and fluid may be readily removed by the 
sponge held in the fingers or in forceps. 

Irrigation of the peritoneum is not often required. It 
is not necessary to flood the peritoneum with water in 
order to wash out blood-clot, which may be removed with 
more accuracy by sponging. There is always danger, 
in general irrigation of the peritoneum, of spreading in- 
fection. 

Local washing of the pelvis is sometimes advisable if 



TECHNIQUE OF GYNECOLOGICAL OPERATIONS. 491 

the operator fears that the field of operation has been in- 
fected by the escape of septic material. Such a condi- 
tion may exist in operations for tubal or ovarian abscess. 
The upper peritoneum should be first shut off from the 
pelvic cavity with a wall of gauze sponges. This may 
be readily done while the patient is in the Trendelenburg 
position. She should then be placed in the horizontal 
position, while the operator, with the left hand pressed 
against the wall of pads, prevents the intestines entering 
the pelvis. The abdominal incision should be held open 
with retractors, and the sterile irrigating fluid should be 
poured in from a flask or a pitcher. The temperature 
of the fluid should be ioo°-ii5° F. The fluid may be 
removed by sponging, and washing may be repeated as 
often as necessary. 

In septic cases the writer has frequently performed such 
local washing with a bichloride solution (1 : 2000 or 1 : 
4000), followed by irrigation with plain water. 

If the patient is horizontal and the gauze pads be 
properly placed, there is no danger of any of the fluid 
entering the upper peritoneal cavity. 

Closing the Abdominal Incision. — A variety of 
methods have been introduced for closing the abdominal 
incision. The simplest method, that is applicable to all 
cases, is the interrupted mass-suture, or the " through- 
and-through" suture. This suture passes through all 
the structures of the abdominal wall (Fig. 205). Some 




FlG. 205 — The mass-suture for closing the abdominal incision: S, skin; F, 
fascia ; M, muscle ; P, peritoneum. 

operators advise passing the suture to, but not through, 
the peritoneum. The writer includes the edge of the 
peritoneum in the suture. These sutures should be placed 



492 A TEXT-BOOK OF DISEASES OF WOMEN. 



two or three to trie inch, according to the thickness of 
the abdominal wall. 

Care should be taken to include all the structures in 
the embrace of the suture. A carelessly applied suture 
sometimes fails to include the retracted fascia and muscle. 
The needle should first be directed outward and then in- 
ward as it passes through the abdominal wall. It should 
not pass directly through, parallel to the sagittal plane 
of the incision. Thus when the suture is tied it forms 
approximately a circle, and the structures included in 
it are brought into a plane of apposition. 

A long straight needle with a spear-point is conveni- 
ent for introducing the mass-suture. A gauze sponge 

should be placed beneath the 
incision as the sutures are 
introduced, to prevent injury 
of the intestines and the escape 
of blood into the peritoneum. 
When the pad is removed, the 
Omentum, if readily found, 
should be drawn down behind 
the incision. Before each 
suture is secured the sides of 
the incision should be drawn 
forward by traction on the 
ends of the suture, to ensure 
accurate apposition upon the 
posterior or peritoneal aspect. 
If this precaution is not taken, 
in a thick or rigid abdominal 
wall the cutaneous aspect of 
the incision may be brought 
into accurate apposition, while 
a gap will exist between the 
Such imperfect apposition is 
The mass-sutures 
The early re- 




Fig. 206 The subcuticular or 

intra-cutaneous suture. The fas- 
cia has been united by an inter- 
rupted suture. 



more posterior structures. 

a frequent cause of ventral hernia. 

should not be removed for two weeks. 

moval of sterile sutures is of no advantage whatever, and 



TECHNIQUE OF GYNECOLOGICAL OPERATIONS. 493 

may cause ventral hernia. The writer often leaves them 
in for three weeks. 

After the sutures are removed the incision should be 
strapped with adhesive plaster. 

The application of a buried suture of catgut or of 
silver wire, passed through the muscle and fascia, is a 
useful addition to the mass-suture and an additional pre- 
ventive of hernia. 

Various methods of uniting the tissues by sutures in 
separate layers are used. A very good method is to close 
the peritoneum by a continuous suture of fine silk, then 
to unite the muscle and fascia by a continuous suture of 
catgut, and finally to close the cutaneous edge with an 
interrupted or a continuous suture of silkworm gut or 
silk. The subcuticular or the intra-cutaneous suture 
(Fig. 206) is very convenient for this purpose. 

If the abdominal wall be fat, it is advisable to intro- 
duce a second catgut suture through the subcutaneous fat. 
When the structures are united in layers, a hematoma 
sometimes forms between two planes of suture, and, if 
not absorbed, the anterior portion of the wound may 
break down. This accident, which is caused by hem- 
orrhage after the sutures are secured, may be prevented 
by employing, in addition to the usual dressing, a com- 
press of gauze placed over the incision. 



CHAPTER XLI. 
TREATMENT AFTER CELIOTOMY. 

The after- treatment of celiotomy is usually very simple. 
A special nurse is required for the first three days. The 
patient should lie upon her back for the first two or three 
days; after this she may be moved partly upon either 
side, and a pillow may be placed behind her for support. 

The head may be supported by one or two pillows. 
Much comfort is experienced by raising the knees over 
pillows. The patient often complains bitterly of back- 
ache, which may be relieved by slipping a folded sheet or 
towel under the small of the back. 

Thirst is always present after celiotomy, and is usually 
the symptom of which the patient complains the most. 
There is much diversity of practice in regard to the ad- 
ministration of water after celiotomy. The writer allows 
no water during the first twenty-four hours. During this 
time the lips and mouth are frequently moistened with 
a cloth wet in cold water or wrapped about a piece of ice. 
At the end of twenty-four hours small quantities of hot 
water or cold soda-water (i dram) are given every fifteen 
minutes or half hour, and gradually increased as it is 
found to be retained by the stomach. Hot water relieves 
thirst as well, and is not so likely to cause vomiting, as 
cold water. 

The chief objection to the early administration of water 
after celiotomy is that it may cause vomiting. Some 
operators avoid this by administering the water by the 
rectum. 

Another reason, more or less theoretical, for withhold- 
ing water is that the absorbing power of the peritoneum 

494 



TREA TMENT OF CELIOTOMY. 495 

is greatest when the tissues of the body contain a deficient 
amount of water. 

Pain after celiotomy seems to bear no relation whatever 
to the amount of traumatism that has been inflicted. 
More discomfort may be experienced after ventro-suspen- 
sion of the uterus than after a hysterectomy. In opera- 
tions upon the generative organs the chief seat of pain is 
in the region of the sacrum. Pain is also felt in the ova- 
rian region and in the abdominal incision. The pain 
begins to abate after the first fifteen or twenty hours. 
Opium should not be administered unless it is absolutely 
necessary to allay nervous excitement in a cowardly wom- 
an. In such a case a small dose (gr. \) of morphine may 
be administered hypodermically. 

The writer rarely finds it necessary to administer an 
anodyne. Most patients are able to endure the pain if 
they are properly encouraged by the physician and the 
nurse. 

There are several objections to the administration of 
opium. It increases the thirst and it diminishes the 
functional activity of the gastro-intestinal tract. It re- 
tards the passage of flatus by the rectum and causes tym- 
panites, and it increases the difficulty of moving the 
bowels. It obscures and delays the recognition of symp- 
toms that may demand immediate treatment. The pa- 
tient who has had no opium is more comfortable at the 
end of three or four days after celiotomy than one to 
whom it has been given. 

The patient should be encouraged to pass water volun- 
tarily. The application of hot moist cloths to the ex- 
ternal genitals sometimes facilitates urination. In many 
cases the use of the catheter is never necessary. If the 
urine is not voided about every eight hours, it should be 
drawn with the catheter. Catheterization should be done 
with strict attention to asepsis. The former frequency 
of cystitis from the improper use of the catheter has 
already been referred to. Catheterization should never 
be performed under any circumstances by the aid of the 



496 A TEXT-BOOK OF DISEASES OF WOMEN. 

tactile sense alone. The nurse should always see what she 
is doing. The catheter — metal, glass, or preferably soft 
rubber — should be sterilized by boiling, and should be 
preserved in a 1 : 20 solution of carbolic acid. 

The catheter may be lubricated with sterilized oil or 
glycerin. The labia should be separated, and the vesti- 
bule and the external meatus should be wiped off with a 
solution of bichloride of mercury (1 : 2000). 

After the catheter has been used once it should be 
thoroughly cleansed, inside and out, and sterilized by 
boiling before being replaced in the carbolic solution. 

The secretion of urine is always diminished for a few 
days after celiotomy, probably on account of the re- 
stricted ingestion of fluids. The writer has found the 
average secretion in in cases of celiotomy on women to 
be, during the first twenty-four hours, 13.4 ounces ; 
during the second twenty-four hours, 14.6 ounces ; during 
the third twenty-four hours, 19.6 ounces. In considering 
these numbers it should be, remembered that the gyneco- 
logical patient passes, before operation, a daily amount 
of urine much less than that passed by the average healthy 
woman. 

Food is usually first administered at the end of forty- 
eight hours. If the patient be feeble, nutriment may be 
given by the mouth or the rectum before this time. The 
patient may have any easily digested food that she wishes, 
such as buttermilk, soup, beef-tea, milk or milk and 
lime-water, soft-boiled egg^ etc. The food should be 
given frequently in small quantities. Buttermilk is one 
of the best foods with which to begin. It gratifies thirst 
and is more readily digested than milk. Half an ounce 
to an ounce may be given every hour until the retentive 
power of the stomach is determined. 

The bowels should be moved at the end of forty-eight 
or seventy-two hours. If the patient is uncomfortable 
and is unable to pass flatus freely, or if there is any ab- 
dominal distention, the purgative should be administered 
at the earlier time (forty-eight hours). If she is comfort- 



TREA TMENT OF CELIO TOMY. 497 

able and passes flatus easily, she may wait for three days. 
Purgation is most readily produced with Rochelle salts, 
given, in doses of x / 2 dram in about 3 or 4 ounces of 
water or soda-water, every hour. After the patient has 
taken five or six doses she usually feels the inclination to 
have a movement. If she is unable to accomplish this, 
she may be assisted with a rectal injection of 1 pint of 
soap and water and 2 drams of turpentine. The bowels 
should be moved at least once in every forty-eight hours 
during the remainder of the convalescence. 

Sometimes the bowels are more difficult to move, and 
it is necessary to repeat the rectal injection at intervals 
•of two or three hours until a good movement is produced. 
A compound enema composed of Epsom salts §j, glycerin 
5J, turpentine 5iss, water iviij, injected high in the bowel 
through a rectal tube, may be effective. If the Rochelle 
salts are not retained, or if they fail to act, 1 grain of 
calomel may be administered every hour for five or six 
hours. 

If the patient does well, vomiting does not often occur 
after the first twenty-four hours, when the effects of the 
ether have passed off. When vomiting occurs later than 
this, it is usually accompanied by abdominal distention 
and general abdominal pain. It is then an alarming 
symptom, and may indicate the onset of intestinal par- 
alysis and general peritonitis. 

This group of symptoms (vomiting, general abdominal 
pain, and distention) demands immediate treatment. A 
hot mustard plaster or a turpentine stupe should be placed 
over the epigastrium, and an enema of 1 pint of water 
and y 2 ounce of turpentine should be administered, and 
should be repeated every three or four hours until a fecal 
movement occurs and flatus is freely discharged. At the 
same time Rochelle salts should be administered, or, 
if there is persistent vomiting, i-graiu doses of calomel. 
The escape of flatus may be assisted by inserting a rectal 
tube. In case of moderate distention or of intestinal 
pain from inability to pass flatus, the insertion in the 



49 8 A TEXT-BOOK OF DISEASES OF WOMEN. 

anus of the ordinary rectal nozzle of the syringe will 
usually give relief. If this is not sufficient, the long 
rectal tube or a large rubber catheter should be intro- 
duced. It should be well greased and passed slowly into 
the rectum for a distance of 10 or 12 inches. 

The patient is sometimes able to pass flatus when upon 
her side, though she may not be able to do so upon her 
back. Inability to pass flatus is not necessarily a sign of 
peritonitis or intestinal paralysis. It may be caused by 
the unaccustomed position, or pain or nervousness may 
prevent the woman relaxing the sphincter ani. 

If the vomiting persists and becomes bilious, relief is 
sometimes obtained by thoroughly washing out the 
stomach through the stomach-tube. 

The internal administration of medicines — except the 
purgatives already mentioned — is of little use in vomit- 
ing of this character. 

The pulse after celiotomy usually remains below 100. 
It often, however, reaches 115 or 120, and sometimes 
higher, in patients who have a favorable convalescence. 
A rapid pulse unaccompanied by unfavorable abdominal 
symptoms often indicates some heart-trouble. 

A pulse of over 120 accompanied by abdominal disten- 
tion and vomiting should always excite alarm. 

Strychnine and digitalis, administered hypodermically, 
are the most useful medicines for strengthening the heart 
and diminishing the rapidity of the pulse. They should 
be given in large doses — 2V °f a grain of strychnine every 
three or four hours, and 10 minims of tincture of digitalis 
at similar intervals. 

Hypodermic injections of strychnine are most useful 
for shock after celiotomy. This drug may be exhibited 
until the physiological action — twitching or jerking of the 
muscles — is observed. The writer has administered be- 
tween 1 and 2 grains during the first twenty-four hours 
after celiotomy, with recovery. 

The temperature after celiotomy runs no regular course. 
It usually remains below 102 ° F. A greater elevation of 



TREATMENT OF CELIOTOMY. 



499 



temperature than this may occur during a favorable con- 
valescence; and, on the other hand, a fatal termination 
may take place when the temperature remains lower. 
The maximum temperature is usually observed about 
the second or third day. 

The temperature often rises on account of very trivial 
causes. It may go up one or two degrees if the patient 



Id 
< 

a 


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CO 

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TEMPERATURE 


' 9 


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4 HOURS AFTER OPERA 


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Fig. 207. — Composite temperature-chart of a series of 150 successful cases 
of celiotomy : average temperatures, pulses, and respirations for two weeks after 
operation. 

should become constipated, and will drop as soon as a 
free fecal movement has taken place. 

The comfort of the patient is much increased by 
sponging the arms and legs with tepid water. The nurse 



500 A TEXT-BOOK OF DISEASES OF WOMEN. 

should be instructed to sponge the patient in this way 
whenever the temperature reaches 102 ° F. 

The patient should maintain the recumbent posture for 
three weeks after celiotomy. She may then sit up in 
bed for two or three days, and if then sufficiently strong, 
she may leave the bed. 

Too great haste in getting up may result in ventral 
hernia. The incision should be strapped with adhesive 
plaster for five or six weeks after operation, and the wom- 
an should wear some simple form of abdominal binder for 
the following six months, or for a year if the incision be 
large. She should be warned against resuming hard 
work, involving lifting or other abdominal strain, for sev- 
eral months after operation. She should be told of the 
possibility of ventral hernia, and advised to return im- 
mediately for treatment should this condition appear. 

The usual causes of death after celiotomy are perito- 
nitis and hemorrhage. The frequency of hemorrhage as 
a cause of death is often overlooked. The writer feels con- 
fident that many deaths which, without post-mortem ex- 
amination, are attributed to peritonitis, are really caused 
by hemorrhage. Without doubt, peritonitis and hemor- 
rhage often occur together; the blood that escapes into 
the peritoneal cavity may be too great in amount for ab- 
sorption, and may become septic. The source of the 
hemorrhage is usually a vessel of the pedicle that escapes 
from the embrace of an imperfectly applied ligature. 
This accident should not happen if the operator is careful 
to see that hemostasis is perfect before the abdomen is 
closed. Bloody oozing from a surface of adhesion is not 
sufficient to cause death, and may be removed by drain- 
age; the fatal hemorrhage conies from an arterial vessel 
that has slipped from its ligature. All ligatured vessels 
should be finally inspected immediately before the abdo- 
men is closed. If a stump is not perfectly dry, a rein- 
forcing ligature should be applied. Care in this particular 
will save much subsequent anxiety. If the operator 
knows that his ligatures have been securely applied, he 



TREA TMENT OF CELIO TOMY. 501 

can exclude the possibility of hemorrhage in case alarm- 
ing symptoms should arise. 

If the symptoms of the patient after celiotomy indicate 
hemorrhage, the abdomen must be reopened and the 
bleeding vessels secured. 

The causes of peritonitis after celiotomy have already 
been discussed. 

The common symptoms are rapid pulse, abdominal dis- 
tention and pain with inability to pass flatus or feces, and 
vomiting, which may finally become stercoraceous. The 
temperature is usually elevated, though it may remain 
normal or subnormal. Auscultation of the abdomen re- 
veals total absence of all peristaltic sounds. If these 
symptoms are not arrested by the use of purgatives, tur- 
pentine enemata, and the rectal tube, it is probable that 
the result will be fatal. Death usually occurs on the 
third day. 

The mortality after celiotomy depends upon the con- 
dition to be treated, the skill of the operator, and the 
environment of the operation. Some operations, like 
ventro-suspension of the uterus, are attended by no mor- 
tality. The average mortality after celiotomy for large 
numbers of gynecological cases of all kinds, in the hands 
of experienced operators with good operative surround- 
ings, is about 5 per cent. 






CHAPTER XLII. 

THE SPECIAL TECHNIQUE OF OPERATIONS UPON 
THE UTERUS AND THE UTERINE APPENDAGES. 

A thorough knowledge of the anatomical relations 
of the various structures in the pelvis is essential for the 
performance of the various operations upon the uterus 
and its appendages. 

A detailed description of such anatomical relations is 
out of place here. It is especially important to study 
the distribution of the arterial supply and the relations 




Fig. 208. — Posterior view of the uterus, the tubes and ovaries, and the broad 
ligaments: I.P.L., infundibulo-pelvic ligament; O.A., ovarian artery; U.A., 
uterine artery ; U., ureter. The utero-sacral ligaments are seen on each side 
of the posterior aspect of the cervix. 

of the ureters. Fig. 208 will refresh the memory upon 
these points. 

The ovarian artery, which corresponds to the spermatic 
in the male, is a branch of the abdominal aorta. It runs 

502 



SPECIAL TECHNIQUE OF OPERATIONS. 503 

tortuously between the layers of the upper part of the 
broad ligament, from the pelvic wall to the upper angle 
of the uterus. Before reaching the uterus it divides into 
two branches. The upper branch supplies the fundus 
uteri; the lower branch anastomoses at the side of the 
uterus with the uterine artery. 

During its course in the broad ligament the ovarian 
artery gives off branches to the ampulla and the isthmus 
of the Fallopian tube, to the ovary, and to the round 
ligament. 

The uterine artery arises from the anterior division of 




Fig. 209. — Anterior view of the uterus, the tubes and ovaries, and the broad 
ligaments. The upper part of the bladder, the anterior wall of the vagina, and 
the peritoneum on the anterior aspect of the broad ligaments have been re- 
moved. U., ureter- U.A., uterine artery; O.A. ovarian artery; R. L., round 
ligament. 



the internal iliac, and runs downward and inward toward 
the cervix uteri. The vessel is tortuous, and is loosely 
supported by the cellular tissue at the base of the broad 
ligament. The lowest point which it reaches is on a level 
with the external os uteri, and at this point it crosses the 
ureter. 



504 A TEXT-BOOK OF DISEASES OF WOMEN. 

At about this point it gives off the circular artery of 
the cervix, which anastomoses with its fellow of the op- 
posite side. The uterine artery then passes upward, and 
reaches the uterus near the level of the internal os. It 
passes along the side of the uterus in a very tortuous 
manner, and anastomoses with the ovarian artery. 

The vaginal arteries usually arise from the anterior 
division of the internal iliac artery. They sometimes 
arise from the uterine or middle hemorrhoidal artery. 

The ureter passes behind and beneath the uterine 
artery. The uterine artery crosses the ureter at about the 
level of the external os uteri. At this point the ureter is 
f of an inch distant from the cervix. The distance be- 
tween the ureter and the artery at the point of crossing 
is about f of an inch. It is important to remember these 
relations in applying a ligature to the uterine artery. 

It must not be forgotten that the anatomical relations 
are altered by any displacement of the uterus from its 
normal position. Such displacement occurs in disease and 
when the uterus is dragged vrpward or downward during 
operation. 

In conditions, such as cancer, which are accompanied 
by hypertrophy of the cervix, the distance between the 
ureter and the cervix is much diminished. 

Removal of the Uterine Appendages (Salpingo - 
oophorectomy). — This operation is performed by liga- 
turing the ovarian artery in its course through the in- 
fundibulo-pelvic ligament and at the uterine cornu, and 
then excising the Fallopian tube and the ovary. 

The peritoneum is opened, and the index and middle 
fingers of the left hand are introduced into the abdomen. 
If necessary, the omentum is swept upward out of the 
pelvis. The fundus uteri is sought, and the fingers, with 
the palmar surface directed downward, are passed over 
the posterior face of the uterus, and then outward over 
the posterior aspect of the broad ligament. The ovary 
and tube are palpated, and are lifted forward upon the 
palmar aspect of the two fingers or between the fingers, 



SPECIAL TECHNIQUE OF OPERATIONS. 505 

perhaps with the subsequent assistance of the thumb, 
into the abdominal incision. The infundibulo-pelvic 
ligament is exposed, and is rendered tense by the pres- 
sure of the fingers behind it. It will be observed that 
the upper edge of the ligament is thick, while there is a 
thin, sometimes transparent, area below the free edge. 
The vessels run in the upper edge of the ligament, and a 
ligature passed through the thin area will secure them 
(Fig. 210). 




Fig. 210. — Salpingo-oophorectomy. On the right side ligatures have been 
placed about the ovarian artery, at the uterine horn, and at the pelvic wall. On 
the left side the tube and ovary have been excised between such ligatures. If 
bleeding takes place from the broad ligament, the anterior and posterior peri- 
toneal aspects may be united by suture. 

The heavy silk carried in the pedicle-needle should be 
used. The ligature should be placed sufficiently near the 
pelvic wall to permit complete excision of the tube and 
ovary without cutting too close to the ligature. The 
broad ligament should then be transfixed by a second 
ligature at a point somewhat to the inside of the first. 
The second ligature should embrace the ovarian liga- 
ment, the isthmus of the tube, and the uterine end of 
the ovarian artery. This ligature should be placed close 
to the uterine cornu, in order to permit complete ex- 
cision of the ovary. 



506 A TEXT-BOOK OF DISEASES OF WOMEN. 

The Fallopian tube, the ovary, and the mesosalpinx 
are then cut away with the scissors. There is usually no 
bleeding whatever from the unligatured portion of the 
broad ligament between the two ligatures. The stumps 
should be carefully inspected, and any bleeding point in 
the intervening portion of the broad ligament should be 
picked up and secured by fine ligature; or the peritoneal 
edges may be united by suture. 

This method of operating is in accord with the best 
surgical principles. 

The vessels are secured in their course by ligatures 
which embrace a minimum amount of surrounding tissue. 
In the early days of modern abdominal surgery, the opera- 
tion usually advised was performed with the Tait knot 
(Fig. 211) or the link-ligature (Fig. 212). 





Fig. 211. — The Tait knot. Fig. 212. — The link-ligature. 

The ovary and the tube are drawn into the abdominal 
incision, and the pedicle formed by the broad ligament is 
transfixed with the pedicle-needle carrying a double liga- 
ture. 

The loop of the ligature is passed over the tube and 
ovary and the Tait knot is tied, or the ligature is cut and 
each half of the pedicle is separately secured, the ligature 
being crossed or linked in the middle of the stump, to 
prevent separation. 

The operators who apply the ligature in this way do so 
because they fear hemorrhage if every portion of the 
broad ligament is not secured. 

This fear is unfounded. The objections to this form 
of ligature, the Tait or the link-ligature, may be given by 
the following quotation from a former paper by the writer. 1 

1 " The Ligature in Oophorectomy," read before the Philadelphia Academy 
of Surgery, February 3, 1896. 



SPECIAL TECHNIQUE OF OPERATIONS. 507 

"The objections to these ligatures are: The liability to 
slip; the difficulty or impossibility in some cases of re- 
moving all the ovary and tube; the fact that the broad 
ligament is puckered up and made more tense than nor- 
mal, and may for this reason cause subsequent pain and 
discomfort; an unnecessary amount of tissue is strangu- 
lated. 

' ' Most operators have seen cases, either in their own 
experience or in the experience of others, in which the 
ligature has slipped from the pedicle, either during the 
operation or some days afterward. I think that this 
accident, usually unrecognized, is a very common cause 
of death after oophorectomy. Tait speaks of a certain 
number of cases in his own experience in which a hema- 
toma occurred in the broad ligament some hours or days 
after operation. He says, ' I cannot form any exact esti- 
mate of how many cases of these operative hematoceles 
I have seen, but it certainly is not less than 50, and is 
more likely to be 70 or 80.' 

u It seems probable that this accident is due to the re- 
traction or slipping of the artery from the embrace of the 
ligature, while the remaining mass of tissue w r hich 
forms the pedicle is still retained, and the hemorrhage, 
therefore, is confined to the broad ligament. I have seen 
this accident happen before the abdomen had been closed, 
and have sought for and ligated separately the retracted 
vessel. 

' ' Slipping of the ligature is due to the form of the 
mass of tissue which is ligated. The broad ligament is 
drawn up into a more or less conical shape, all parts con- 
verging toward the ligature, and the ligature is really 
placed at the apex of a cone from which it may readily 
slip; and the elastic artery, tied when upon the stretch, 
tends to retract and escape from the embrace of the liga- 
ture. 

" The second objection is the difficulty or impossibility 
of removing all the ovary and tube. If the broad liga- 
ment is tense, as it often is in single women, or if it is 



508 A TEXT-BOOK OF DISEASES OF WOMEN. 

thickened from inflammatory deposit, it is sometimes im- 
possible to bring the tube and ovary through the abdom- 
inal incision and to obtain a pedicle which may be ligated 
so that we may with safety remove all of the ovary. 
And it is in just such cases that it is usually most desira- 
ble that all. ovarian tissue should be removed. 

"The third objection — the puckering and tension of 
the broad ligament — may be of less importance than 
those just considered. However, it seems probable that 
some of the pain which women suffer after oophorectomy 
is due to the traction and counter-traction exerted by 
different parts of the broad ligament upon a sensitive 
cicatrix. The broad ligament is pulled up from different 
directions and converges to the cicatrix, which becomes 
the point from which the lines of traction radiate. 

"It was thought that in case of retroversion this ten- 
sion of the broad ligament would maintain the uterus in 
place, the ligaments acting as guys. This, however, is 
not true. Repeated secondary operations have shown 
that the uterus has fallen back again to extreme retro- 
version, notwithstanding such methods of ligature of the 
broad ligaments. 

"The fourth objection is one which appeals to our 
surgical sense. It is always better surgery to ligate 
the vessel alone than to include with it a mass of sur- 
rounding tissue." 

If the isthmus of the Fallopian tube is diseased, as in 
some cases of pyosalpinx, so that it is necessary to exsect 
the tube from the uterine cornu, the second ligature may 
be passed immediately beneath the tube, including the 
ovarian ligament and the ovarian artery, but not includ- 
ing the tube; the tube may then be cut out by a wedge- 
shaped incision in the horn of the uterus. The uterine 
wound should be closed by interrupted suture (Fig. 212, A). 
In such cases, however, if the tubal disease is bilateral, 
it is best to remove the uterus as well as the appendages. 

It is not necessary to place both ligatures before cut- 
ting away the ovary and tube. The first ligature may 
be placed about the proximal portion of the ovarian 



SPECIAL TECHNIQUE OF OPERATIONS. 509 




Fig. 212, A. — Position of ligatures and sutures in exsection of the tube. 




FlG. 212, B. — Pyosalpinx which has been exsected from the uterine cornu. 



510 A TEXT-BOOK OF DISEASES OF WOMEN. 

artery, and then the infundibulo-pelvic ligament may be 
cut, bleeding from the distal end being controlled with 
forceps. This will enable the operator readily to bring 
the ovary and tube through the incision and to ligate the 
ovarian artery at the uterine cornu. 

If adhesions exist, they should be broken with the 
fingers, or the patient should be placed in the Trendelen- 
burg position and the adhesions should be divided with 
scissors. The tube and ovary are sometimes completely 
imbedded in adhesions, and it is necessary to shell them 
out by careful work with the fingers. The adhesions 
may be so dense and the anatomical relations so altered 
that it is difficult or impossible to determine what is ovary 
and what is tube until the mass is brought into the abdom- 
inal incision. In these cases the experienced operator may 
work by the sense of touch alone. The inexperienced 
operator had better expose the parts and obtain the as- 
sistance of visual examination. 

The fundus uteri can usually be determined, and will 
form a valuable landmark. The enucleation is most 
easily performed with the fingers. The index and middle 
fingers, with the palmar surfaces turned downward, 
should be passed outward from the posterior aspect of the 
uterus, and should seek a plane along which the struc- 
tures most readily separate. As a rule, adhesions give 
way more easily than the tissues of normal structures. 
Adhesions should not be roughly torn: they should be 
pushed away from the posterior aspect of the ovary and 
broad ligament. 

The adhesions between the ovary and the broad liga- 
ment must be broken by pressure with the fingers before 
the ovary can readily be brought into the abdominal in- 
cision. 

After all other adhesions have been relieved it is often 
found that the ovary still lies low in the pelvis, glued to 
the posterior aspect of the broad ligament. It should 
not be dragged, in this condition, into the incision, or 
the broad ligament may be badly lacerated. It should 



SPECIAL TECHNIOUE OF OPERATIONS. 511 

be peeled off from the broad ligament and rolled up to 
the incision. 

After the structures have been carefully examined and 
the anatomical relations determined the ligatures should 
be placed and the tube and ovary cut away. The bleed- 
ing from the pelvic adhesions is usually arrested or much 
diminished as soon as the ovarian artery is ligated. It is 
best, therefore, to waste no time in attempts to arrest 
moderate hemorrhage until the appendages have been re- 
moved. The pelvis should then be inspected and any 
bleeding points secured. Omental adhesions should be 
ligated, if necessary, as they are divided. 

If there is a general oozing from the bed of adhesions 
that cannot be controlled by ligature, one or two gauze 
pads should be pressed over the region and retained there 
until the abdominal sutures have been placed. If the 
bleeding continues notwithstanding such sponge-pressure, 
it may be necessary to employ drainage. The bleeding 
may always be controlled by the pressure of the end of 
the gauze drain placed directly over the raw surface. 

If the operator is anxious to arrest menstruation, he must 
be certain to remove all ovarian tissue and the Fallopian 
tubes at the uterine cornua. Sometimes, after an adhe- 
rent ovary has been enucleated, part of the ovarian 
stroma remains glued to the pelvic wall, the posterior 
face of the broad ligament, or some other structure. 
These portions of ovary should be carefully picked 
off with the forceps. If the operator doubts the com- 
plete removal of all ovarian tissue, he should make a 
note to this effect in the history of the case. Were this 
always done, the existence of a supernumerary ovary 
would not be so often assumed. 

The directions that have been given here apply to the 
removal of tubal tumors and small cystic and solid tumors 
of the ovary. When the ovary is removed there is but 
little, if any, advantage in leaving the corresponding 
Fallopian tube in case the tube 011 the opposite side is 
healthy. 



512 A TEXT-BOOK OF DISEASES OF WOMEN. 

If the, patient is anxious for children, the operator 
should remember that conception is possible with one 
tube and one ovary, though they be on opposite sides. 
If an ovarian tumor is removed independently of the 
corresponding Fallopian tube, the pedicle of the ovary 
should be transfixed and ligatured in two or more masses. 

Removal of an Ovarian Cyst.— The removal of a 
large ovarian cyst may be facilitated by preliminary tap- 
ping as soon as the peritoneum is opened, and withdrawal 
of the fluid contents. As a general rule, this procedure 
is advisable if the cvst is too large to be removed through 
a 3- or 4-inch incision. If, however, the operator should 
suspect the contents of the cyst to be septic, it is safest 
to enlarge the incision and to remove the tumor intact, 
thus avoiding infection of the peritoneum. This advice 
is especially applicable to dermoid cysts. The contents 
of such cysts are very often septic. They are ; thick, and 
contain a large amount of solid material which passes 
with difficulty through the trocar. The walls of the cyst 
are friable and easily torn' so that the puncture-wound 
of the trocar becomes enlarged and the cyst-contents 
escape around it; and, finally, the contents of a dermoid 
are very difficult to remove from the peritoneum. 

The dermoid character of a cyst may be suspected from 
the dull appearance of the walls and the putty-like feel- 
ing upon palpation. They are usually of small size, and 
may be removed bodily through an incision of moderate 
extent. 

Every tumor should be carefully examined before the 
trocar is plunged into it. The operator should make 
certain by palpation that the tumor is cystic. The trocar 
has been thrust into the pregnant uterus, and frequently 
into a fibroid tumor. In the case of a fibroid profuse 
hemorrhage may occur from such an accident. The 
hemorrhage may usually be controlled by forcing a small 
sponge or gauze pack into the puncture wound. Before 
tapping the cyst the operator should pass his hand around 
it and determine the position and character of adhesions. 



SPECIAL TECHNIQUE OF OPERATIONS. 513 

Small cysts about the size of a child's head may be 
tapped with the small trocar. The larger instrument is 
used in cysts of greater size. 

In a multilocular cyst the largest loculus should be 
tapped first. Sponges should be placed in the abdomen 
around the point selected for puncture. An incision 
about half an inch in length should be made through the 
outer coat of the cyst, and the trocar should then be in- 
troduced. As the fluid escapes through the trocar and 
the rubber tube into a vessel at the side of the table, and 
as the cyst becomes flaccid, the wall of the cyst near the 
trocar should be seized with large forceps. As the tumor 
diminishes in size it should be dragged through the ab- 
dominal incision. This procedure should not be done 
quickly or roughly, or adherent intestines may be torn, 
and bleeding from omental adhesions may escape detec- 
tion. 

As the cyst is drawn out the surface should be exam- 
ined and adhesions should be separated, and ligatured, if 
necessary, as they appear. Omental adhesions usually 
require ligature. The bleeding from omental vessels is 
often profuse and is not arrested spontaneously. An ad- 
herent omentum should be ligatured with medium-sized 
silk in small sections, not in one mass, before it is cut 
away from the tumor. 

The intestine is sometimes so adherent to the surface 
of the tumor that it cannot be separated without serious 
danger to the intestinal wall. In such a case it is best 
to cut out the adherent portion of the outer wall of the 
tumor and leave it glued to the intestine. If there is 
bleeding from the raw surface, it may be checked by 
folding in the bleeding area with silk suture. 

While the operator is dealing with the adhesions the 
assistant should see that the opening in the cyst is kept 
in a dependent position and that cyst-contents do not 
escape into the abdomen. This precaution should always 
be taken, though it is especially important in the cases 
•of septic and papillomatous cysts. 
33 



514 A TEXT-BOOK OF DISEASES OF WOMEN. 

When the pedicle of the cyst is exposed, it should be 
ligatured as already advised. If the stump of the pedicle 
is very broad, it may be folded in or covered with peri- 
toneum to prevent intestinal adhesions to it. 

The other ovary should always be examined before 
closing the abdomen. 

Operation for the Removal of Intraligamentous 
Cysts. — Intra-ligamentous cysts grow between the folds 
of the broad ligament. Any oophoritic tumor may be 
intra-ligamentous, though the condition is most usually 
found in cysts of the paroophoron and the parovarium. 

The intra-ligamentous cyst may drag out the broad 
ligament so that a pedicle may be formed, and the tumor 
may be removed by the methods already described. 

In other cases, however, the cyst is strictly sessile. It 
lies between the layers of the broad ligament, deep in the 
pelvis, or perhaps it may have migrated to some other 
part of the abdomen behind the peritoneum. 

The removal of such tumors requires accurate ana- 
tomical knowledge of the re'gion in which the growth is 
situated. 

It is necessary to incise the peritoneal covering of the 
tumor and to enucleate it from its bed. The peritoneum 
should be incised in the position in which there are few- 
est blood-vessels. Thus, if the tumor has migrated be- 
tween the layers of the mesocolon, the incision should be 
made through the outer peritoneal layer. 

Intra-ligamentous cysts often have no pedicular attach- 
ments whatever, and may be enucleated without the ap- 
plication of ligature. In other cases a distinct vascular 
pedicle is found after the peritoneal investment has been 
opened and its adhesions to the cyst-wall have been sep- 
arated. 

The relations of an intra-ligamentous cyst should be 
carefully examined before the surgeon proceeds with the 
operation, and such a cyst should not be mistaken for an 
extra-ligamentous cyst that has become adherent. 

If the tumor is situated between the layers of the broad 



SPECIAL TECHNIQUE OF OPERATIONS. 515 

ligament, it is advisable, as a preliminary step, to ligate 
the ovarian artery in the infnndibulo-pelvic ligament and 
at the cornu of the uterus. This may usually be readily 
done; much subsequent bleeding will be prevented by it. 

The peritoneum is then incised at the most convenient 
point over the surface of the tumor, and the surgeon, 
with the fingers, knife-handle, or closed blunt scissors, 
proceeds with the enucleation. If inflammatory adhe- 
sions have not taken place, enucleation is usually easy. 
Bleeding vessels should be secured by forceps as they ap- 
pear, and should be ligated, if necessary, after the cyst is 
removed. 

If a pedicle or fleshy adhesion is met, it should be 
ligated before division. 

During the enucleation the surgeon should follow closely 
the surface of the tumor. When he has reached a point 
deep in the pelvis he should be especially careful to avoid 
injury of the large vessels and the ureter. If the cyst is 
difficult of removal in this region, it may be advisable to 
cut out a portion of the cyst-wall and leave it. 

Preliminary tapping of intra-ligamentous cysts is not 
often necessary. They are usually of moderate size, and 
enucleation may be most readily performed if the cyst is 
tense. 

Sometimes large cysts are but partly intra-ligamentous: 
the greater portion is free, while the base is included be- 
tween the layers of the broad ligament. In such cases it 
is best to tap the cyst and then to enucleate the base as 
already described. 

In other cases the process of enucleation may be facili- 
tated and rendered safe by incising the cyst-wall and in- 
troducing two fingers into the cavity to act as guides in 
separating the cyst from structures deep in the pelvis. 

After the cyst has been removed and bleeding points 
have been secured by ligature, the raw surface, or the bed 
of the tumor, may be obliterated by bringing the sides 
into apposition by layers of buried fine silk sutures and 
by closing with suture the incision in the peritoneum. 



516 A TEXT-BOOK OF DISEASES OF WOMEN. 

These raw surfaces often contract very much by the fall- 
ing together of the sides after the tumor has been re- 
moved. 

If bleeding from the bed of the tumor cannot be thor- 
oughly arrested, it is unsafe to close the incision in the 
peritoneum, for a hematoma will form and will cause sub- 
sequent trouble. In such a case the gauze drain should 
be introduced into the bed of the tumor, perhaps after 
partial closure of the peritoneal incision. Or if the bleed- 
ing be very profuse, the edges of the incision in the 
broad ligament should be sutured to the lower angle of 
the abdominal wound, and the cavity should be packed 
with gauze. 

The sutures that attach the broad ligament to the ab- 
dominal incision may be passed through the whole thick- 
ness of the abdominal wall, or through only the fascia, 
muscle, and peritoneum. The ends of the sutures should 
be left long to facilitate removal. 

In the removal of a cyst of the parovarium by enucle- 
ation, the tube and ovary should not be sacrificed unless 
they are diseased. Small cysts of the parovarium which 
develop between the layers of the mesosalpinx may very 
easily be removed by simple incision of the peritoneal 
capsule and enucleation of the cyst, without injury to 
the tube and ovary. 

Marsupialization of the Cyst. — In rare cases a cyst 
is found to be so firmly and generally adherent to sur- 
rounding structures that its removal is impossible. It is 
then necessary to practise marsupialization. 

The cyst should be evacuated with the trocar, which is 
introduced at a point which can be readily brought to the 
abdominal incision. Vegetations, etc. should be removed 
from the interior of the cyst with the fingers. The 
opening in the cyst should then be attached to the lower 
angle of the abdominal incision by interrupted sutures 
of strong silk that pass through the whole thickness of 
the abdominal wall and of the cyst-wall. The sutures 
should be placed close together, and the ends should be 



SPECIAL TECHNIQUE OF OPERATIONS. ' 517 

left long to facilitate removal. The upper portion of the 
abdominal incision should be closed with interrupted 
sutures. 

A large double drainage-tube of rubber should be intro- 
duced into the cyst, and strips of gauze should be packed 
around the tube. 

The subsequent treatment consists of frequent washing 
of the interior of the cyst. The sutures in the cyst-wall 
should be removed at the end of two weeks. 

Though marsupialization frequently results in cure, yet 
it should never be practised unless it is absolutely neces- 
sary. It exposes the patient to the dangers of prolonged 
suppuration and persistent fistula. Malignant degenera- 
tion has occurred in the wound. Papilloma may extend to 
the peritoneum. The procedure is of but little use in the 
case of multilocular tumors, as all the loculi cannot be 
evacuated. 



OPERATION FOR REMOVAL OF THE UTERUS. 

The uterus may be removed through an abdominal in- 
cision (abdominal hysterectomy), or it may be removed 
through the vagina (vaginal hysterectomy). A combina- 
tion of the two methods of operating is sometimes em- 
ployed. 

In many conditions it is not necessary to remove the 
cervix. Partial hysterectomy or supra-vaginal amputa- 
tion of the uterus at some convenient point of the cervix 
may be performed. 

Such supra-vaginal amputation of the uterus may be 
done in nearly all operations that are not performed for 
malignant disease. In sarcoma or cancer the whole 
uterus should be removed at the vaginal junction, and, 
if necessary, the upper portion of the vagina should be 
excised. 

In the case of fibroid tumor and in non-malignant dis- 
ease of the body of the uterus supra-vaginal amputation 
is sufficient. Supra-vaginal amputation is an easier and 



518 A TEXT- BO OK OF DISEASES OF WOMEN. 

safer operation than complete hysterectomy. Abdominal 
hysterectomy is most easily performed with the patient 
in the Trendelenburg position. 

Supra-vaginal Amputation of the Uterus. — After 
the abdomen has been opened, the ovarian artery should 
be ligated in the infundibulo-pelvic ligament, as in the 
operation of salpingo-oophorectomy. A second ligature, 
or forceps, should then be placed upon the ovarian artery 
at the uterine cornu. 

The round ligament should then be ligatured with 
medium-sized silk at a point situated about an inch from 




Fig. 213. — Supra-vaginal amputation of the uterus, first step: ligatures have 
been placed on the ovarian arteries and the round ligaments. 

the uterus. Similar ligatures should then be placed about 
the ovarian artery and the round ligament on the opposite 
side. 

The infundibulo-pelvic ligament immediately outside 
of the abdominal ostium of the tube, the round liga- 
ment between the ligature and the cornu, and the broad 
ligament as far as the uterus should then be divided with 
scissors on each side. 

The uterus is thus freed from all its attachments down 



SPECIAL TECHNIQUE OF OPERATIONS. 519 

to a point somewhat above the level of the internal os. 
The vessels that remain to be secured are the uterine 
arteries. 

The peritoneum is next divided by a transverse incision 
across the anterior face of the uterus, immediately below 
the line of reflection of the peritoneum from the uterus 
to the bladder. This incision should join at each end 
the incisions that had been previously made in dividing 
the broad ligaments. 



■ ' ; -*'- *'■ 


M 




^w 




M- 




\ J ^'J/ 


f f-' / 




Star* 


f -w 



Fig. 214. — Supra-vaginal amputation of the uterus, second step : the broad liga- 
ments have been divided down to the level of the internal os uteri. 

The bladder should then be dissected from the anterior 
face of the uterus and cervix, down to the vaginal junc- 
tion. 

The bladder is but loosely attached to the uterus, and 
may be readily pushed off with the finger or with 
closed scissors. The finger pressed out to a short distance 
on each side of the cervix will push away the anterior 
layer of the broad ligament with the bladder, so that the 
uterus is perfectly free in front. 



520 A TEXT-BOOK OF DISEASES OF WOMEN. 

The posterior layer of the broad ligament and the 
cellular tissue may then be divided, with scissors, along 
the side of the uterus down to a point somewhat below 
the level of the internal os. This incision should not be 
made too close to the uterus, or the uterine artery that 
runs up along side of the uterus and cervix may be 
divided. The operator should place one or two fingers 
upon the posterior aspect of the broad ligament, immedi- 
ately beside the cervix, and while the uterus is drawn 
upward should pass a heavy ligature beneath the tissue 
that includes the uterine artery. The pulsation of the 
uterine artery may usually be felt by the finger placed be- 
hind the broad ligament. This ligature includes the cell- 
ular tissue at the base of the broad ligament, the uterine 




Fig. 215. — Supra-vaginal amputation of the uterus, third step : the peritoneum 
has been incised across the anterior face of the uterus ; the bladder has been 
dissected from the cervix ; the bases of the broad ligaments have been opened ; 
the uterine arteries have been secured by ligatures placed between the ureters 
and the cervix. 

artery, and part of the posterior peritoneal layer of the 
broad ligament. It does not pass through the anterior 



SPECIAL TECHNIQUE OF OPERATIONS. 521 

peritoneal layer of the broad ligament, which had been 
previously dissected away. The ligature should be placed 
as closely as possible to the cervix without including 
cervical tissue. It should be remembered that the ureter 
lies about half an inch from the side of the normal cervix 
and at the level of the external os. The ureter is usually 
more remote than this when the ligature is passed, be- 
cause the uterus is drawn upward and the ureter is pushed 
aside by the fingers at the side of the cervix. 

The uterine artery should be secured in a similar way 
upon the opposite side. 

The bases of the broad ligaments should then be 
divided with scissors between the cervix and the ligatures 
of the uterine arteries. To prevent slipping of the liga- 
ture, ample tissue should be left between the incision and 
the ligature. As the cervix is not malignant, the incision 
may be made as close to this structure as necessary. 




Fig. 216. — Supra-vaginal amputation of the uterus, fourth step: the uterus 
has been amputated below the level of the internal os ; sutures have been intro- 
duced to close the stump of the cervix. 

The uterus should then be amputated by a wedge- 
shaped incision through the cervix, making an anterior 
and a posterior flap. 



522 A TEXT-BOOK OF DISEASES OF WOMEN. 

When the cervical canal is opened, it may be immedi- 
ately sterilized with a solution of bichloride of mercury 
(i : 500). 

As the uterus is cut away the flaps of the cervix are 
secured with forceps. The cervical stump is usually 
white and dry. 

The flaps of the cervix should next be united by inter- 
rupted silk suture. Care should be taken to avoid pass- 
ing a suture through the cervical canal, as it might be- 
come infected. 

The anterior peritoneal layer of the broad ligament 
and the peritoneal reflection from the bladder are then 
drawn over the field of operation and secured by fine silk 
sutures to the posterior peritoneal layer and the posterior 
aspect of the cervix. The stump of the cervix, the 




Fig. 217. — Supra- vaginal amputation of the uterus, completed operation: the 
anterior and posterior peritoneal layers of the broad ligament have been united 
by sutures; the peritoneal covering of the bladder has been drawn over and 
sutured to the posterior aspect of the stump of the cervix. 

stump of the uterine arteries, and the cellular tissue of 
the broad ligaments are thus covered by peritoneum. The 
only raw surfaces exposed are the stumps of the ovarian 
arteries and of the round ligaments. These surfaces may 
also be covered if the operator so desires. 



SPECIAL TECHNIQUE OF OPERATIONS. 523 

Preservation of the Ovaries in Hysterectomy. — 

Many surgeons consider it advisable to leave the ovaries 
in hysterectomy for fibroid tumor of the uterus in case 
these organs are not diseased. If the woman has not yet 
reached the menopause the disagreeable symptoms of the 
artificially induced menopause are thus avoided, and any 
metabolic function that the ovaries may possess is pre- 
served. In hysterectomy for fibroid in women under forty 
years of age with healthy ovaries it is advisable to leave 
these organs if this can be done without seriously compli- 
cating the operation. _ 

The ovarian artery should be ligated between the ovary 
and the uterus and the broad ligament should be divided 
inside of this ligature. The tubes may be left if they can 
not readily be removed. 

Complete Abdominal Hysterectomy. — In this ope- 
ration the uterus is removed at the vaginal junction. The 
operation is absolutely necessary in cases of malignant 
disease of the body and neck of the uterus. It is not 
often necessary in the treatment of the other conditions 
for which hysterectomy is performed. The operation re- 
quires a longer time than the operation of partial hyste- 
rectomy; it is often accompanied" by profuse bleeding 
from the edge of the divided vagina; there is more danger 
of injury to the ureters, and there is more danger of sep- 
tic infection, because the vagina is opened; and, finally, 
the operation very considerably shortens the vaginal 
canal. 

The first steps in the operation of complete hysterec- 
tomy are the same as those in partial hysterectomy. In 
the case of malignant disease of the cervix the ligatures 
on the uterine arteries should be placed as far from the 
cervix as possible without including the ureters. 

Some surgeons advise the preliminary introduction of 
bougies into the ureters in order to locate these structures 
and thus prevent injury to them. If the operator is sure 
of the position of the ureter he may ligate the uterine 
artery upon the outer side of the ureter, and carry the 



524 A TEXT-BOOK OF DISEASES OF WOMEN. 

incision through structures well outside of the diseased 
cervix. 

After the vessels have been secured and the bladder 
has been separated from the uterus and the upper part of 
the vagina, and the broad ligaments have been divided 
down to the vagina, a transverse incision is made with 
the knife or scissors into the anterior vaginal fornix. 
The position of the anterior vaginal fornix may be deter- 
mined by palpation and percussion. A drum-like sound 
is obtained by snapping the finger upon the tense vaginal 
wall. 

With the finger in the opening in the anterior vaginal 
fornix as a guide, the incision is continued around the 
sides and posterior wall of the vagina. The edge of the 
vagina is secured by forceps, and bleeding vessels in the 
walls are ligated. When hemostasis is complete the 
vagina is closed by sutures that pass through the outer 
portions of the walls, but do not enter the vaginal canal. 
The peritoneum is then drawn over the field of opera- 
tion and the abdomen is closed. If hemostasis is not 
perfect, gauze drainage through the vagina or the abdom- 
inal incision must be employed. 

Some operators do not ligate the uterine arteries until 
the vagina has been opened. The ovarian arteries are 
secured, the bladder is separated from the uterus and the 
upper part of the vagina, and the broad ligaments are 
divided down to a point somewhat below the level of the 
internal os. 

The anterior vaginal fornix is then opened, and the 
incision is carried around toward the lateral fornices as 
far as may be done without injury to the uterine arteries. 
The uterus is then drawn forward and the posterior vag- 
inal fornix is opened, the finger introduced through the 
opening into the anterior fornix acting as a guide. 

The uterus is now attached to the body only by two 
lateral bands of tissue that include the cellular tissue at 
the base of the broad ligament, the uterine artery, and a 
strip of vaginal mucous membrane over the lateral vag- 



SPECIAL TECHNIQUE OF OPERATIONS. 525 

inal fornix. This band of tissue, exclusive of the vag- 
inal mucous membrane, is then secured by a ligature that 
does not enter the vagina, but passes immediately above 
the strip of vaginal mucous membrane. A finger intro- 
duced into the vagina serves to guide the ligature-needle. 
The uterus may then be cut away. 

The ligatures of the uterine arteries are sometimes left 
long, the ends being carried down into the vagina and a 
gauze drain being introduced into the vagina, the upper 
portion of the drain reaching just above the level of the 
stump of the uterine arteries. 

The peritoneum may be left open, or it may be drawn 
over the drain and the field of operation as already de- 
scribed. 

Drainage through the vagina in this way is advisable 
if the hemostasis be not perfect and if the operator fears 
septic infection. 

In hysterectomy for cancer of the cervix it is usually 
advisable to remove as much as possible of the cancerous 
mass by a preliminary operation two or three days before- 
hand. The diseased tissues should be cut away with the 
knife, scissors, and the sharp curette, the cavity seared 
w T ith the thermo-cautery, and closed by approximation of 
the edges with a few silk sutures. The dangers of septic 
infection and of transplantation of cancer-cells during the 
hysterectomy are thus diminished. 

The surgeon should always keep in mind the possibility 
of the transplantation of cancer-cells from diseased into 
healthy tissues. It seems very probable that some cases 
of recurrence have been due to this cause. During hys- 
terectomy the operator should therefore avoid, as much 
as possible, cutting into or manipulating the cancer mass. 
Instruments, such as hemostatic forceps and volsella for- 
ceps, which have grasped diseased tissue, should not be 
used upon healthy tissue without previous sterilization; 
and sponges and pads which have been in contact with 
the cancerous tissue should be discarded. 

The methods of operating just described, modified to 



526 A TEXT-BOOK OF DISEASES OF WOMEN. 

meet special indications, are applicable to all cases in 
which hysterectomy is required. 

Sometimes, in cases of fibroid tumor, the broad liga- 
ment is very much hypertrophied and contains enormous 
veins, and additional ligatures besides those on the ova- 
rian and uterine arteries are required. It is often neces- 
sary to place a large number of forceps upon bleeding 
vessels on the surface of the tumor as it is cut away from 
the broad ligament. 

The anatomical relations are often very much dis- 
turbed, and it may be impossible to determine the posi- 
tion of the cervix and the uterine arteries until the 
greater part of the tumor has been freed from its connec- 
tions. Sometimes the tumor so fills the pelvis that it is 
impossible to ligate, at first, both ovarian arteries. The 
operator must first attack the more accessible side, ligate 
the ovarian artery, cut away the broad ligament, strip 
off the bladder, ligate the uterine artery, and perhaps 
divide the cervix, before he proceeds to the other side. 
Bleeding from the tumor must be controlled by the care- 
ful application of forceps or ligatures. An inaccessible 
uterine artery is sometimes most readily reached in this 
way from below, after the attachments upon the opposite 
side have been divided and the cervix has been ampu- 
tated. Some operators perform hysterectomy in all cases 
by ligating and cutting away from above downward 
on one side — the more accessible — then cutting across 
the cervix, and ligating and cutting away on the opposite 
side from below upward. 

The difficulties are greatest in the case of intra-liga- 
mentous fibroids. Such operations are among the most 
difficult in surgery. The directions given for the treat- 
ment of intra-ligamentous cysts are applicable also to this 
condition. The surgeon should always at first secure the 
ovarian arteries if possible. He should then incise the 
peritoneal investment across the anterior or posterior face 
of the tumor. 



SPECIAL TECHNIQUE OF OPERATIONS. S 2 7 

Enormous veins often lie immediately beneath the peri- 
toneum, and care must be taken to avoid injuring them. 

The peritoneum should be stripped off with the fingers 
or with blunt scissors. Bleeding vessels are secured with 
forceps as they appear. No attaching structures should 
be divided until they have been carefully examined, for 
all anatomical relations are distorted by these growths. 
The ureter may pass over the top of the tumor, far re- 
moved from its normal position on the pelvic floor. 

After the surgeon has started the enucleation of a 
tumor of this kind he must complete the operation. 
Bleeding cannot be arrested until the tumor has been 
enucleated, the cervix exposed, and the uterine arteries 
secured. 

The operation is often accompanied by very profuse 
hemorrhage, but this hemorrhage is always arrested by 
the ligature of the ovarian and uterine arteries, which 
alone supply the growth. The surgeon should therefore 
not delay the operation by the ligature of separate bleed- 
ing points until the main vessels have been secured. 

Vaginal Hysterectomy. — Vaginal hysterectomy may 
be performed for the relief of any condition in which 
the uterus or attached tumor is sufficiently small to pass 




Fig. 2 i 8. — Lateral vaginal retractor. 

through the vagina. The operation is very popular with 
some surgeons. It is but rarely used by the writer. The 
difficulty in dealing with adhesions and other complica- 
tions in the upper part of the pelvis seems to be much 
less when the operation is performed through an abdom- 
inal incision. 



528 A TEXT-BOOK OF DISEASES OF WOMEN. 

The technique of vaginal hysterectomy varies con- 
siderably in the hands of different operators. The vag- 
inal vault is opened with the knife, the scissors, or the 
cautery. The vessels ^i the broad ligament are secured 
with the ligature or with the clamp. The uterus is 
sometimes divided by longitudinal incision and the halves 
are separately removed. 




Fig. 219. — -Vaginal hysterectomy with clamps: first step (Baldy). 

The following are the general directions for the per- 
formance of the operation: 

The woman is placed in the lithotomy position. The 
vagina is opened with the Sims speculum and with lateral 
vaginal retractors (Fig. 218). 

If the cervix is septic, it is thoroughly curetted, steril- 



SPECIAL TECHNIQUE OF OPERATIONS. 529 

ized with the cautery or by other means, and the sides of 
the excavation are united by suture. 

The cervix is seized by tenaculum forceps and dragged 
downward and forward. 

A transverse incision with knife, scissors, or cautery is 
made in the posterior vaginal fornix, and Douglas's pouch 
is opened. 




Fig. 220. — Vaginal hysterectomy with clamps : second step (Baldy). 

A sponge is introduced into the peritoneum behind 
the uterus. 

Some operators suture the posterior peritoneal layer 
of Douglas's pouch to the posterior vaginal wall, to 
control bleeding and to prevent stripping of the perito- 
neum. 

34 



530 A TEXT-BOOK OF DISEASES OF WOMEN. 

The cervix is now dragged backward and a transverse 
incision is made across the anterior vaginal fornix. 

The bladder is carefully dissected from the anterior 
face of the cervix with the knife, scissors, and finger, 
and the utero-vesical fold of peritoneum is opened. The 
peritoneum and the anterior vaginal wall may here also 
be united bv suture. 




Fig. 221. — \ 



Paginal hysterectomy with clamps : third and final step (Baldy). 



An incision may then be made through the vaginal 
mucous membrane of the lateral fornices, uniting the 
anterior and posterior incisions. 

With a finger in Douglas's pouch as a guide, the 
broad ligaments are then secured in successive portions 
by ligature or by strong clamp forceps, and the uterus is 
cut away with the scissors as the ligatures or clamps are 
placed. 



SPECIAL TECHNIQUE OF OPERA TIONS. 531 

As the upper portion of the broad ligaments is reached 
the procedure may be facilitated by retroverting or ante- 
verting the uterus, the fundus being dragged through the 
posterior or the anterior incisions in the vaginal vault. 

The tubes and ovaries should be removed when possi- 
ble, especially in the case of malignant disease. 

After the uterus has been removed the vagina may be 
packed with a gauze drain that reaches upward between 
the stumps of the uterine arteries; or, if ligatures have 
been used, the vaginal vault may be closed. The for- 
mer procedure is the safer. When the gauze drain is 
used, it is advisable to leave the ends of the ligatures on 
the uterine arteries long and protruding into the vagina. 
The ligatures usually become infected, and their removal 
is facilitated by this procedure. If clamps are used, they 
should be removed in forty-eight hours. 

The treatment after vaginal hysterectomy is the same 
as that already described after celiotomy. 

Combined Vaginal and Abdominal Hysterec- 
tomy. — A combined vaginal and abdominal operation is 
sometimes performed in order to enable the surgeon to 
deal with adhesions and other complications in the upper 
part of the pelvis. 

The operation is usually begun below. The vaginal 
connections and the bladder are separated from the ute- 
rus, and the bases of the broad ligaments are secured 
with the ligature or the clamp; the cervix is freed from 
its attachments to the broad ligament. 

The abdomen is then opened and the operation is fin- 
ished from above, the uterus being removed through the 
abdominal incision. 

The writer performs the combined operation in the re- 
verse order, as follows: 

The abdomen is first opened. The ovarian arteries 
and the round ligaments are secured by ligature. The 
bladder is separated from the uterus and the upper part 
of the vagina. The broad ligaments are divided to a 
point somewhat below the level of the internal os. 



532 A TEXT-BOOK OF DISEASES OF WOMEN. 

A gauze pad is then introduced to the bottom of Doug- 
las's pouch, and another to the bottom of the space be- 
tween the uterus and the bladder. The abdominal incis- 
ion is then closed. 

The rest of the operation is performed through the 
vagina. The posterior and anterior vaginal fornices are 
opened by incisions made directly upon the gauze pads. 
The vaginal mucous membrane is divided over the vag- 
inal fornices by an incision that joins the anterior and 
posterior incisions in the vaginal vault. The bases of the 
broad ligaments are secured by strong clamp-forceps, and 
the uterus is cut away and removed through the vagina. 
The gauze pads are then removed, and the vagina is 
drained with gauze introduced as far as the upper end of 
the forceps. 

The following are the advantages of the latter method 
of operating: 

If sterilization of the vagina and the cervix is not per- 
fect, the cleaner part of the operation is performed first. 
The bladder is more easily separated from the uterus by 
operating from above than by way of the vagina. The 
vaginal vault is quickly and safely opened by incisions 
made upon the gauze pads, which keep the intestines 
out of the way. 

The uterus and the infected cervix are removed through 
the vagina, and not through the abdominal cavity. 

If the operation is performed for cancer of the cervix, 
the incision is made more accurately beyond the limits 
of the disease if the vaginal vault is opened through the 
vagina than if it is opened from above. 

Werder, of Pittsburg, has advised the following com- 
bined operation: The abdomen is opened, and the uterus, 
tubes, and ovaries are freed as in ordinary hysterectomy. 
The ureters are dissected out, and the uterine arteries 
are ligated near their origin. The bladder is entirely 
freed from the uterus, and also, for a considerable dis- 
tance, from the vagina. The recto-vaginal space is 
then opened, and the posterior vaginal wall is stripped 



SPECIAL TECHNIQUE OF OPERATIONS. 533 

from the rectum as far down as necessary. The lateral 
vaginal attachments are loosened. The uterus and 
vagina are then pushed down into the pelvic outlet, and 
the peritoneum from the anterior pelvic wall is united 
with that covering the rectum, thus shutting off the 
pelvis from the general peritoneal cavity and covering 
all raw surfaces with peritoneum. The abdomen is then 
closed. 

The patient is then placed in the lithotomy position. 
The uterus — which is found protruding at the vulva — is 
seized with volsella forceps and drawn completely out of 
the vulvar orifice with the inverted vagina. With the 
finger in the rectum and the sound in the bladder as 
safeguards against injuring these organs, the inverted 
vagina is amputated with the knife or the thermo- 
cautery. The chief advantage of this operation is that 
a large vaginal cuff may be removed. 

Abdominal Myomectomy. — In some cases of uterine 
fibroid it is proper to remove the tumor without taking 
away the uterus. This operation — myomectomy — is per- 
formed as follows : 

The abdomen is opened by a free incision, the pelvis 
is elevated, and the intestines are displaced from the 
pelvic cavity in the usual manner. The tumor and the 
uterus are surrounded by gauze sponges, and, where pos- 
sible, should be brought outside the abdominal cavity. 
An incision is made around the pedicle or through the 
capsule of the tumor, and it is enucleated by dissection 
with the sharp or the blunt end of the scalpel. During 
the operation hemorrhage may be controlled by an assis- 
tant, who compresses with his fingers the vessels on each 
side of the uterus, or by placing a temporary rubber liga- 
ture about the cervix uteri. 

Hemostasis is effected and the wound in the uterus is 
closed by layers of continuous or interrupted catgut 
sutures. Great care should be taken to prevent hemor- 
rhage between the layers of suture, and to insure accu- 
rate closure of the incision in the uterus. The tern- 



534 A TEXT-BOOK OF DISEASES OF WOMEN. 

porary ligature about the cervix, or the compression of 
the vessels of the broad ligaments, should be removed 
from time to time during the process of suturing and 
after closure of the uterine wound, in order to determine 
the position of bleeding points and the efficiency of the 
hemostasis ; and before closing the abdominal incision 
the uterine wound should be inspected for several 
minutes while the woman is in the horizontal position. 
The abdomen may usually be closed without drain- 
age. 



CHAPTER XIvIII. 

THE EFFECT OF THE REMOVAL OF THE UTERINE 
APPENDAGES. 

Removal of the tube and ovary upon one side has no 
effect upon menstruation or upon any of the other cha- 
racteristics of the woman. 

Removal of the tubes and ovaries upon both sides is 
followed within forty-eight hours by slight bleeding from 
the uterus, lasting for one or two days. 

If the removal of the tubes and ovaries has been com- 
plete, menstruation, in the majority of cases, never re- 
appears. 

In a few cases menstruation appears for one, two, or 
three periods after the operation, usually in diminished 
amount, and then ceases for ever. In some other cases 
there is a period of a few months of amenorrhea, fol- 
lowed by two or three scanty menstrual flows, before the 
bleeding permanently ceases. 

These phenomena, it will be observed, are similar to 
those of the normal menopause. 

The woman after double salpingo-oophorectomy expe- 
riences the nervous and gastro-intestinal disturbances 
that so usually accompany the menopause. She, in fact, 
passes through a premature menopause, the phenomena 
of which may persist for one or two years. 

The secondary sexual characteristics of the woman — the 
voice, the figure, and the growth of hair — are not altered 
if the appendages are removed during adult life. The 
case may be different if the appendages are removed in 
the undeveloped girl, in whom the ovarian influence is 
essential for complete development. 

The woman loses none of her feminine attractions. 



53^ A TEXT-BOOK OF DISEASES OF WOMEN. 

She may, indeed, become better-looking if the operation 
has relieved chronic suffering. It is said that Gyges, 
king of Lydia, caused the removal of ovaries from wom- 
en with a view to prolonging their charms. 

Double oophorectomy may be followed by obesity if 
the woman have a tendency to form fat. The relief of 
suffering and the consequent improved nutrition favor the 
development of obesity. There seems to be nothing in- 
herent in the operation to cause it. Many women remain 
thin after the operation. 

The emotions of the woman are unaltered by double 
oophorectomy, with the exception of some cases in which 
the sexual desire is destroyed. Sexual desire is depend- 
ent upon such a variety of conditions, both within and 
without the woman, that it is difficult to determine the 
amount of influence that removal of the ovaries exerts 
upon this feeling. 

It is undoubtedly true that sexual desire is sometimes 
destroyed by the operation. On the other hand, the sex- 
ual desire is very often restored by the operation, which 
relieves the former dyspareunia, or painful coitus. 






NDEX. 



Abdomen, binder for, 479 

distention of, after celiotomy, 497 

drainage of, 480, 482 

enlargement of, 19 

examination of, 19, 21, 22, 28 

exploration of, 489 

fluctuation in, 24 

protection of contents of, during 
operation, 489 

retentive power of, 99 

sterilization of, for operation, 473 
Abdominal incision, closing of, 49 1 

irrigation, temperature of water for, 
468 

myomectomy, 255 
technique, 530, 533 

operations, dressing of, 479 
instruments for, 475 

section, after-treatment of, 494 

surgery, training for, 461 

suture, layer method, 493 

sutures, removal of, 492 

wall, incision of, 487 
closing of, 491 
Abortion by uterine sound, 35 

in endometritis, 206 
Abscess, pelvic, 303 

of yulvo-vaginal glands, 38, 40 
Actinomycosis of tubes, 313 
Adeno-carcinoma of cervix, 181 
Adenoma of ovary, 354 

of tubes, 313 

of uterus, malignant, 221 
Adenomyoma of uterus, 257 
Adhesions of clitoris, 48 

pelvic, treatment, 510, 513 
Alexander's operation, 142 
Amenorrhea, 405 

emansio mensium, 405 

in superin volution, 217 

in tubal pregnancy, 326 

pelvic massage in, 414 

periodical disturbances in, 406 

suppressio mensium, 405 
Ampullar pregnancy, 315 
Anesthesia, 470 
Anesthetizer, duties of, 470 



Animals, disease of reproductive 

organs in, 17 
Anteflexion of uterus, 119 

causes, 119, 122 

menstruation in, 122 

miscarriage in, 123 

pessaries in, 123 

pregnancy in, 123 

sequelae, 122 

sterility in, 122 

symptoms, 122 

varieties, 120 
Anterior colporrhaphy, 90 
Antisepsis, 35 
Antiseptics, action of, on peritoneum, 

457 

Apoplexy of ovary, 346 

Apparatus for gynecological opera- 
tions, 462 

Appendix vermiformis, palpation of, 
21 

Applicator, vesical, 425 

Arnold's sterilizer, 466 

Ascites in ovarian cyst, 366 
in solid tumors of ovary, 391 

Asepsis, importance of, in gynecology, 
458 

Atresia of cervix, 17 

of vagina, 17, 52 

diagnosis, 53 

symptoms, 52 

treatment, 53 

Auscultation of abdomen, 22 

Barnes' bag in inversion, 269 
Bartholin's glands, 36 
Basham's mixture, 171 
Basins, sterilization of, 463 
Bimanual examination, 23-25, 2S 
in carcinoma of uterus, 224 
in endometritis, 206 
reposition of uterus, 135 
Binder, abdominal, 470 
Bivalve speculum, 20, 30 
Bladder, base of, 436 
body of, 430 
catheterization of, 430 

587 



538 



INDEX. 



Bladder, cervix of, 436 

dissection of, from uterus, 519 

empty, 436 

examination of, 34, 425 

fundus of, 436 

intra-ureteral ligament of, 437 

irrigation of, 443 

irritable, 89 

meatus internus, situation of, 445 

mucous membrane of, 436 

neck of, 436 

structure of, 436 

trigone of, 436 

vascular supply of, 437 

vesical triangle of, 436 
Blaud's pill, 170 
Boldt's table, 462 
Bowels, treatment of, after celiotomy, 

496 
Braun's colpeurynter, 118 
Broad ligament, hematoma of, 318 
Bulbo-cavernosus, 58 
Buried sutures, 493 

Calculi in vesico-vaginal fistula, 416 

vesical, 447 
Calibrator, urethral, 423 
Canal of Gartner, 52 

of Nuck, 42 
Carcinoma, cachexia of, 192 
of cervix, 181 

adeno-carcinoma, 181 

broad ligaments in, 185, 193, 194 

caustics in, 196 

diagnosis from lupus, 188 

from syphilitic ulceration, 188 
from uterine polyp, 188 

duration, 193 

hysterectomy for, 193, 194 
remote results, 195 

metastasis in, 185 

origin, 181 

peritoneal involvement in, 185 

septic infection in, 192 

squamous-cell, 181 

symptoms, 189 

treatment, 193, 195 

ulceration in, 182 

ureteral involvement in, 185 

urinary fistulae in, 185 

varieties, 181, 183, 184 
of Fallopian tubes, 220 
of ovaries, 220 
of peritoneum, 220 
of ureters, 185 
of uterus, body of, 218 

age, 220 

causes, 221 

curette in, 224 



Carcinoma of uterus in lower animals, 

influence of fibroids in, 221 
leucorrhea in, 223 
metastasis in, 220, 223, 224 

operation in, 224, 225 
symptoms, 222 
of vagina, 52 
urethral, 436 
Carrier for perineal sutures, 66 
Caruncle, urethral, 434 
results, 435 
symptoms, 435 
treatment, 435 
Catarrh of cervix, 166 
Catgut, sterilization of, 477, 478 
cumol method, 478 
iodin method, 478 
Catheter, Skene's, 429 
Catheterization after celiotomy, 495 
as cause of cystitis, 438 
before operation, 474 
of bladder, 439 
Celibacy a cause of disease, 18 

fibroids in, 18 
Celiotomy, 305, 308 

abdominal distention after, 497 
after-treatment, 494 

of bowels, 495 
catheterization after, 495 
death after, 500 
dressings after, 478 
food after, 496 
hemorrhage after, 500 
micturition after, 495 
mortality after, 501 
opium after, 495 
pain after, 495, 497 
peritonitis after, 500 
pulse after, 498 
purgation after, 496 
shock after, 498 
temperature after, 498 
thirst after, 494 
urinary secretion after, 496 
vomiting after, 497 
water after, 494 
Cellulitis, pelvic, 303 
Cervical catarrh, 153, 166 
erosion in, 167 
in displacements, 167 
in laceration of cervix, 152 
sclerosis in, 167 
Cervix, amputation of, 162, 163 
conception after, 165 
in subinvolution of uterus, 216 
in uterine prolapse, 117 
applications to, 172 
artery of, 504 



INDEX. 



539 



Cervix, atresia of, 17 

carcinoma of, 181. See also Carci- 
noma. 
chancre of, 180 
congenital erosion of, 174 

split of, 177 
cystic degeneration of, 152, 155 
dilatation of, 124 
results of, 126 
direction of, 95 
distance of, from coccyx, 95 
ectropion of, 150, 152, 159 
endometritis of, 166 
erosion of, after laceration, 176 
erosions of, 152, 155 
e version in laceration of, 150 
examination of discharge from, 452 
gonorrhea of, 451 
hypertrophic elongation of, 178 
in infancy, 119 
laceration of, 148 
diagnosis of, 154 

from congenital ectropion, 176 
Nabothian cysts in, 152, 184 
reflex symptoms, 154 
sclerosis in, 152 
subinvolution in, 152 
symptoms, 153 
trachelorrhaphy in, 156 
treatment, 156 
ulceration in, 152 
varieties, 150 
with endometritis, 153 
of bladder, 436 
patulous canal, 206 
polypi, 178 

polypoid growths, 182 
sensation of, 27 

splitting posterior lip of, for inver- 
sion of uterus, 271 
supra- vaginal elongation of, 104 
tuberculosis of, 180 
ulceration of, 182 
vegetating growths of, 182 
Chancre of cervix, 180 
Chorio-epithelioma, 228 
symptoms, 229 
treatment, 229 
Circular artery, ligation of, 196 
Claudius' method for sterilization of 

catgut, 478 
Clitoris, adhesions of, 48 
Clothing as cause of disease, 17 
Coccygodynia, 54 
Colpeurynter, Braun's, 118 
Colporrhaphy, anterior, 82 
Conception after amputation of 
cervix, 165 
after salpingo-oophorectomy, 512 



Corpora fibrosa, 390 

Corpus-luteum cyst, 352 

Cumol method for sterilization of 

catgut, 478 
Curette in endometritis, 207, 208, 299 

in uterine cancer, 224 

Martin's 209 

perforation by, 210 

reparative process after use of, 212 

Sims', 209 
Cyst, intra-ligamentous, removal of, 

Nabothian, 152 
of hernial sac, 42 
of Morgagni, 369 
of ovary, 15. See also Ovary. 
of round ligament, 42 
of vagina, 51 

of vulvo-vaginal gland, 40 
trocar, 477 
urethral, 435 
Cystitis, 89 
chronic, 438 

causes, 438, 439 

cystotomy in, 444 

diagnosis, 439 

effect on system, 29 

hypertrophy of bladder-wall in, 

438 
use of endoscope in, 440, 442, 444 
obstruction of vesical orifice, 438 
result of lacerated perineum, 440 

of uterine displacement, 440 
symptoms, 439 
treatment, 440, 444 
ureter and kidney involvement, 438 
urinary changes, 438 
Cystocele, 88, 107 

Dudley's operation for, 91 
Sims' operation for, 90 
Cystoscope, 424 
Cystotomy, 444, 445 

Death after celiotomy, 500 

Depressor for vagina, 29 

Dermoid cysts, 359 
of ovary, 512 

age of occurrence, 359 

Developmental errors a cause of dis- 
ease, 17 

Diarrhea, vicarious, 40S 

Dilatation of cervix, 124 
of urethra, 433 

Dilator, cervical, 123 
vaginal, 416 

Diseases of women, causes of, 16 

Dorsal position, 31 

Drainage, abdominal, by gauze, 482 
by tube, 480 



54o 



INDEX. 



Drainage, abdominal, ill effects of, 

485 
indications for, 484 
object of, 485 
vaginal, 480, 487 
Drainage-tube, 480, 482 
cleansing of, 481 
syringe for, 481 
Dressings for abdominal operations, 
478 
sterilization of, 466 
Duck-bill speculum, 29 
Dudley's operation for cystocele, 91 
Dysmenorrhea in anteflexion of uterus 
121 
in salpingitis, 291 
membranous, 212 
menstruation in, 210 

Ectropion, cervical, 152 
Edebohls' stirrups, 22 
Elephantiasis Arabum, 47 

of vulva, 47 

syphilitic, 47 
Emansio mensium, 405 
Emmet's operation for lacerated peri- 
neum, 80 

perineal needles, 65 
scissors, 64 

treatment for inversion of ute*rus, 
269, 270 
Endometritis, abortion in, 206 

acute, 199 

cervical, 166 

chronic, 201, 207 
causes of, 207 
curette in, 208 

examination in, 206 

exfoliative, 212 

fungous, 203 

gonorrheal, 199 

in exanthemata, 199 

in lacerated cervix, 153, 204 

in subinvolution, 204 

in tubal disease, 204 

influence on menstruation, 204 
with metritis, 199 

ovarian disease in, 204 

pain in, 205 

post-climacteric, 213 

puerperal, 199, 200 

senile, 213 

sterility in, 206 

structural changes in, 203 

with uterine displacement, 131, 204 
Endoscope, 432 

in cystitis, 440, 442, 444 
Enterocele, 91 
Erosion of cervix, 152, 174, 176 



Eruptive fever as cause of disease, 

344 
Exanthemata as cause of chronic 
pelvic disease, 200 
of cystitis, 439 

of sexual ill-development, 200 
vaginitis in, 49 
External genitalia, examination of , 22, 

26 
Extra-uterine pregnancy, 314. See 
also Tubal pregnancy. 

Facies ovariana, 381 
Fallopian tubes, 272 

actinomycosis of, 28 

adenoma of, 313 

anatomy of, 272 

cancer of, 313 

cysts of Morgagni, 276 

development of, 395 

examination of, 25 

gummata of, 313 

inflammation of, 276. See also 
Salpingitis. 

miliary tuberculosis of, 308 

myoma of, 313 

pregnancy in, 314. See also 
Tubal pregnancy. 

sarcoma of, 313 

tubercle of, 307 

tuberculosis of, 306, 309, 312 
unsuspected, 308 
Fibroid tumors, anatomic changes, 

2 35 
hysterectomy in, 526 
in Africans, 16 
in animals, 15 
in celibacy, 18 
of uterus, 230 

and ovarian cyst, 248 

and pregnancy, 247, 256 

appearance of, 232 

circulatory abnormalities in, 

245 
degenerations of, 237, 238 
diagnosis of, 246, 248 
duration of life in, 236 
frequency of, 241 
gangrene in, 239 
hemorrhage in, 242 
hypertrophy in, 242 
hysterectomy in, 254 
in menopause, 242 
interstitial, 232 
intra-ligamentous, 232, 235, 

526 
intra-uterine polyp, 234, 256 
ligation of uterine arteries in, 

252 



INDEX. 



541 



Fibroid tumors of uterus, lymphan- 
giectatic, 238 
menstruation, in, 241, 242, 249 
myomectomy in, 255 
necrobiosis of, 239 
polypoid, 256 
pressure-symptoms of, 245 
procreative abnormalities in, 

240, 250 
prognosis in, 248 
salpingo-obphorectomy in, 252 
sarcoma of, 239 
submucous, 232, 234 
subperitoneal, 232 
telangiectatic, 238 
treatment of, 249, 251 
of vagina, 52 
recurrent, 227 
inversion of, 227 
metastasis in, 227 
tubal changes in, 237 
sterility in, 18 
with cancer, 227 
Fibroma, ovarian, 390 
Fibro-myoma of uterus, 227 
Fibro-sarcoma of uterus, 227 
Fissure, vesico-urethral, 431 
Fistula in salpingitis, 290 
needles for, 418 
of vulvo-vaginal glands, 39 
recto-vaginal, 421 
uretero-vaginal, 421 
urethro-vaginal, 420 
vesico-uterine, 420 
vesico-vaginal, 412 
Flatus after abdominal section, 497 
Floating kidney, 21 
Fluctuation, abdominal, 20 
Follicular vulvitis, 36 
Food after celiotomy, 496 
Forceps, bladder, 423 
Four chlorids, 171 
Fungous endometritis, 203 

Gartner's canal, 52 

duct, 368 
Gauze sponges, preparation of, 468 
Genital fistulae, 412 

tract, septic infection of, 17 
Genitalia, development, 395 

examination, 22 

inflammation of glands of external, 

454 

malformations of, 395 

preparations of, for operation, 472 
Genu-pectoral position, 32 
Glands of Bartholin, 36 

of Skene, 426 
Gloves, rubber, 465 



Gonococci in gonorrhea, 450 
Gonococcus, resistance to, 451 

of vagina, 453 
Gonorrhea, 448 

a cause of disease, 17, 37, 450 
auto-infection, 453 
best time for examination, 455 
carbolic acid in, 456 
curettement in, 456 
epidemics of, 450 
gonococci in, 450 
in children, 450 
liability to, 451 
of cervix uteri, 451, 453 
examination, 452 
of discharge, 452 
of rectum, 450 
of urethra, 451 
of vagina, 453 

symptoms of, 454 
of vulva, 454 
persistence of, 451 
results of, 17 
Gonorrheal endometritis, 453 
macula, 39 
vaginitis, 453 
Green soap, 26 

Gummata of Fallopian tubes, 313 
Gynecological operations, apparatus 
for, 462 
performance of, 460 
personal sterilization in, 463 
rubber gloves in, 465 
water in, 467 
Gynecology, definition of, 15 

Hands, sterilization of, 465 
Headache in endometritis, 205 

in lacerated cervix, 153 
Hematocele, pelvic, 325 
Hematocolpos, 53, 399 
Hematoma between suture planes, 

493 

of broad ligament, 318 

of vulva, 46 

pelvic, 326 
Hematometra, 259 
Hematosalpinx, 282, 286, 287 

after celiotomy, 500 

in cervical carcinoma, 190 

with hematometra, 260 
Hemorrhage after rupture of tubal 
pregnancy, 317 

in carcinoma of fundus uteri, 223 

in uterine fibroid, 242 
Hemostatic forceps, Tait's, 470 
Hermaphroditism, 399 

hypospadia in, 400 
Hernia, entero-vaginal, 91 



542 



INDEX. 



Hernial-sac cyst, 42 
Hodge pessary, 134 
Hydrocele of canal of Xuck, 42 

ovarian, 346 
Hydrometra, 259 
Hydrosalpinx, 282, 285, 289 

with hematometra, 260 
Hydrostatics of pelvic contents, 98 
Hvpertrophic cervical elongation, 178 
Hypospadia, 400 

Hysterectomy, abdominal, 517, 523 
supra-vaginal amputation, 518, 

5 21 

combined abdominal and vaginal, 

53 1 
advantages of author's method, 

533 
\\ erder's, 532 
for cervical carcinoma, 193, 194 
complete, 523 
dangers, 523 
incisions of vaginal fornix in, 

5 2 4 . 
indications for, 523 
remote results, 195 
transplantation of cancer-ceUs 
during, 525 
for fibroid, 526 ♦ 

for inversion, 271 
for prolapse, 117 
for salpingitis, 302 
for uterine fibroid, 254 
preservation of ovaries in, 523 
vaginal, 517, 518 

removal of tubes and ovaries, 531 

Incision of abdominal wall, 487 
Infundibular pregnancy, 315. See 

also Tubal pregnancy. 
Inguinal adenitis, 36 

hernia, 42 
Instillation-tube, 173 
Instruments for abdominal oper- 
ations, 475 
sterilization of, 466 
Interstitial pregnancy, 315. See also 

Tubal pregnancy. 
Intestinal tract, evacuation before 

operation, 471 
Intestines and omentum, protection 

of, during operations, 489 
Intra-ligamentous cyst, marsupializa- 
tion, 516 
removal, 514 
Intra-ureteral ligament, 437 
Intra-vesical pressure, 437 
Inversion of uterus, 264 
Barnes' bag in, 269 
continuous pressure in, 270 



Inversion of uterus, diagnosis of, 267 
Emmet's method for, 269, 270 
hysterectomy in, 271 
splitting posterior lip of cervix 

for, 271 
symptoms and sequelae of, 266 
treatment of, 268 
White's repositor for, 270 
with uterine polyp, 271 
with vaginal prolapse, 265 

Irrigation after curettement, 210 
of abdominal cavity, water for, 467 

Kelly's instruments for examination 

of bladder, 423 
Kidney, floating, 21 

movable, 21 
Knee-chest position, 32 

for rectal examination, t>3 
Kobelt's tubes, 368 
Kolpokleisis, 420 
Kraurosis vulvae, 44 

Labor after amputation of cervix, 165 

spurious, 321 
Laceration of cervix, 148 
concealed, 150 
incomplete, 150 

of perineum, 62 
Latero-abdominal position, 31 
Le Fort's operation for prolapse, 112 
Leucorrhea, 153 

in carcinoma of fundus uteri, 223 

vicarious, 408 
Levator ani, 53 
Ligament, intra-ureteral, 437 

of uterus, 95, 96 

utero-sacral. 27 
Ligation of circular artery, 196 

of uterine arteries, 196 
Ligatures, 476, 477 
Lineae albicantes, 19 
Link ligature, 506, 508 
Lupus ulceration, diagnosis from car- 
cinoma of cervix, 188 
Lymphadenitis in lacerated cervix, 

Lymphangitis in lacerated cervix, 154 

Malformations of genital organs, 

395 
Malignant adenoma, 221 
Mammary changes in tubal preg- 
nanes, 322 

secretion, periodical, 408 
Manometer, 437 
Marsupialization, 516 
Mass suture, 491 
Massage, pelvic, 299 



INDEX. 



543 



Meatus interims, position of, 445 
Mechanism of perineum, 56 

of uterine support, 95 
Median perineal laceration, repair of, 

70 
Membranous dysmenorrhea, 212 
Menopause, 405, 409 

due to salpingo-oophorectomy, 535 

in chronic oophoritis, 344 

in ovarian cysts, 380 

in salpingitis, 294 

in uterine fibroid, 242 

operative, 511 
Menorrhagia in chronic endometritis, 
204 
oophoritis, 344 
Menstruation after curettement, 212 

after salpingo-oophorectomy, 535 

amount of flow in, 404 

and ovulation, coincidence of, 402 

arrest of, by operation, 511 

cessation, of, 405 

constituents of fluid of, 404 

disorders of, 402 

duration of flow, 404 

during pregnancy, 247 

establishment of, 402 

frequency of, 404 

in anteflexion, 95 

in chronic endometritis, 204 

in lacerated cervix, 153 

in retro-displacement, 133 

in tubal pregnancy, 322 

neglect during, 18 

precocious, 404 

regimen during, 18 

scanty, 407 

suppression of, acute, 407 

systemic effect of, 18 

vicarious, 408 
Metastasis in carcinoma of cervix, 

185 
Metritis in subinvolution, 215 

with endometritis, 199 
Metrorrhagia in chronic endometritis, 

204 
Micturition after celiotomy, 495 
Miliary tubal tuberculosis, 298 
Milk as a diagnostic agent in fistulas, 

414, 421 
Miscarriage in anteflexion, 123 
Morgagni, cysts of, 276, 369 
Mortality after celiotomy, 501 
Movable kidney, 21 
Miiller, ducts of, 395 
Muscles of perineum, 58 
Myo-fibroma, uterine, 230 
Myoma of Fallopian tubes, 313 

uterine, 230 



Myomectomy, abdominal, 255 

technique of, 530, 533 
Myxoma, ovarian, 390 
peritoneal, 378 

Nabothian cysts, 152 
Necrobiosis in uterine fibroid, 239 
Needle for cervix, 156 

for fistula, 418 

for perineum, 65 
Needle-holder, Emmet's, 65 

Reiner's, 477 
Neoplasms of vulva, 46, 49 
Normal salt solution, 468 
Nuck, canal of, 42 
Nurse's duties in operating-room, 470 

Obturator, 33 

Oophoritis, 339. See also Ovary, in- 
flammation of. 
Operating-room, 461 
discipline of, 470 
preparation of, 462 
temperature of, 462 
Operating-table, 462 
Opium after celiotomy, 495 
Ostium vaginse, 57 
Ovarian abscess, 283 
adenomata, 354 
artery, 502 

ligation of, 520, 526 
carcinomata, 392 
cyst, _ 15 

axial rotation in, 375 
dermoid, 512 
duration of, 382 
examination of, 383 
inflammation of, 374, 382 
malignant degeneration of, 380 
marsupialization of, 515 
necrosis of, 377 
operation for, 389 
pregnancy, 329 
pressure results of, 379 
rapidity of growth, 381, 382 
removal of, 512 
rupture of, 377, 382 
causes of, 383 
symptoms of, 383 
treatment of pedicle, 514 
suppuration of, 375 
symptoms of, 378, 382 
tapping of, 387, 512, 513 
thrombosis, 377 
torsion of pedicle in, 375 

symptoms of, 382 
treatment of, 387, 389 
fibroid uterus, changes in, 237 
fibromata, 300 



544 



INDEX. 



Ovarian fibro-myomata, 288 

ligament, bimanual examination of, 

25 
tumors of, 394 

myomata, 390 

papillomata, 393 

sac, 348 

sarcomata, 391 

tuberculosis, 393 
Ovaritis, 339. See also Ovary, in- 
flammation of. 
Ovary, accessory, 333 

after menopause, 330 

anatomy of, 330 

apoplexy of, 346 

blood-vessels of, 332 

chronic inflammation, treatment of, 

344 
contents of glandular cyst of, 356 
corpus luteum, cyst of, 352 
cystic, 342 

cystic, tumors of, 349 
dermoid cysts of, 350, 359 
follicular cysts of, 350 
hemorrhage in, 346 
glandular cysts of, 354, 372 
hernia of, 334 

conception in, 334 ♦ 

dangers in, 334 
menstruation in, 334 
ovulation in, 334 
treatment of, 335 
hydrocele of, 346 
in multiparas, 330 
in new-born, 330 
inflammation of, acute, 339 
causes of, 340 
symptoms of, 340 
treatment of, 341 
chronic, 341 

reflex disturbance in, 344 
from salpingitis, 283 
ligaments of, 331 
maintenance of position of, 332 
multilocular cyst of, 354 
of virgin, 330 
of Wolffian body, 333 
oophoritic cysts of, 350, 372 
odphoron, 335 
papillomatous cyst of, 362 
contents of, 364 
in ascites, 366 

peritoneal involvement in, 365 
rupture of, 365 
paroophoritic cysts of, 362, 373 
ascites in, 366, 380 
contents, 364 
dangers, 365 
wall of, 362 



Ovary, paroophoron, 333 

pedicle of glandular cyst of, 358 
preservation of, in hysterectomy, 

523 
prolapse of, 335 

causes, 335 

diagnosis from retroflexion, 337 

pessary in, 339 

reflex symptoms, 337 

secondary changes, 336 

treatment of, 337, 339 
tuberculosis of, 393 
veins of, 332 
Ovulation and menstruation, coinci- 
dence of, 402 
Oxyuris, 37 

Pain after celiotomy, 495, 497 

in carcinoma of fundus uteri, 223 

in cervical carcinoma, 191 

in salpingitis, 292 

in uterine fibroid, 244 
Palpation of abdomen, 20 
Papilloma of ovary; 393 

of vulva, 46 
Papillomatous ovarian cysts, 362 
Parenchyma body, 359 
Paroophoritic cysts, 262, 373 
Paroophoron, 333 
Parovarium, 52, 368 

cysts of, 368, 370, 373 

Gartner's duct, 368 

Kobelt's tubes, 368 

papillomatous cysts of, 370 
Parturition as cause of retro-displace- 
ments, 130 

results of injuries during, 16 
Patient, preparation of, for operation, 

471 
Pedicle-needle, 476 
Pelvic abscess, 303 

after rupture of tubal pregnancy, 

3i7 
celiotomy for, 305 
vaginal evacuation of, 304 
contents, hydrostatics of, 98 
massage, 299 

in amenorrhea, 407 
structures, rectal examination of, 28 
Pelvis, local washing of, 489 

suppuration of cellular tissue in, 
302 
Percussion of abdomen, 22 

in ascites, 22 
Perineal laceration involving one or 
both vaginal sulci, 75, 79, 80 
recto-vaginal septum, 73, 74 
loss of support in, 69, 75, 130 
repair, 70 



INDEX. 



545 



Perineal laceration, sphincter-tear, 
suture-introduction, 68, 71, 
72 
removal of sutures, 73 
subcutaneous, 79, 85 
needle, Emmet's, 65 
needle-carrier, 66 
scissors, Emmet's, 64 
Perineorrhaphy, 62, 63, 80 
after-treatment of, 66 
intermediate, 63 
passage of sutures in, 67, 68 
primary, 62 
secondary, 64 
Perineum, anatomy and mechanism 
of, 56 
characteristics after sulci-tear, 78, 

79 . . i 
of uninjured, 74 
fasciae of, 57 
injuries to, 62 
lacerations, classification of, 80 

Emmet's operation for, 80 
ligaments, 57 
median laceration of, 67 

involving sphincter, 68 
muscles, 57 
Peri-oophoritis, in inflammation of 

ovary, 339 
Peritoneum, action of antiseptics on, 

457 £ o 

causes of infection of, 485 

cleansing before operation, 490 

infection in minor gynecology, 458 

toilet of, 490 
Peritonitis after celiotomy, 500 
Pessary, contraindications to use, 141 

Hodge, 134 

in anteflexion, 123 

in retro-displacement, 133, 146 

Smith, 133 

stem, 123 

Thomas, 134 

vaginal, 133, 138, 140 
Pfliiger, tubes of, 354 
Phantom tumor, 386 
Polypi of cervix, 178, 182 

tubal pregnancy and, 314 

urethral, 435 

uterine, 234, 256 

with endometritis, 203 
Position, dorsal, 31 

genu-pectoral, 31, 32 

knee-chest, 31, 33 

latero-abdominal, 31 

of uterus, 94 

Sims', 31, 32 

Trendelenburg, 462, 510 
Post-climacteric endometritis, 213 

35 



Pregnancy after amputation of cervix, 

165 
after celiotomy, 389 
after curettement, 212 
as cause of prolapse, 108 
extra-uterine, 314. See also Tubal 

pregnancy. 
in anteflexion, 123 
influence on anteflexion, 123 
ovarian, 329 

tubal, 314. See also Tubal preg- 
nancy. 
with uterine fibroid, 247, 256 
Probe, vesical, 425 
Prolapse of ovary, 335. See also 
Ovary. 
of urethra, 431 
of uterus, 75, 101 

amputation of cervix in, 117 
causes, 102, 108 
colpeurynter in, 118 
cystocele and rectocele in, 107 
diagnosis, no 
hysterectomy for, 117 
LeFort's operation, 112 
pessaries, 118 
sequelae, in 
structural changes, 106 
subjective symptoms, 108 
treatment, no 
ventro-fixation in, 113 
of vagina, 75 
Pruritus vulvae, 42 

diabetes as cause, 43 
etiology, 42, 43 

excision of mucous membrane, 44 
treatment, 43 
Pseudo-hermaphroditism, 400 
Pseudo-mucin, 356 
Pulse after celiotomy, 498 
Purgation after celiotomy, 496 
Pus, sterile, 284, 486 
Pyelitis, result of cystitis, 438 
Pyocolpos, 53 
Pyometra, 259 

Pyosalpinx, 260, 282, 284, 2S7, 509 
cholesterin deposits in, 285 
conversion into hydrosalpinx, 285 
micro-organisms in, 284 
reinfection, 285 
rupture of, 289 
spontaneous evacuation, 284 
sterile pus, 284 

Rectal examination of pelvic struc- 
tures, 28 
of uterus, 27 
specula, 33 
tube in abdominal distention, 498 



546 



INDEX. 



Rectocele, 77, 87, 107 
Recto- vaginal fistulae, 421 

septum, laceration of, 73 
Rectum examination, ^ 

knee-chest position for, 33 
Recurrent fibroid, 227 
metastasis in, 227 
origin of, 227 
uterine inversion in, 227 
Reflux tube in uterine irrigation, 210 
Reiner's needle-holder, 477 
Replacement of uterus, 135 
Reposition, bimanual, 135 

instrumental, 136 
Repositor, White's, 270 
Retractor for vagina, 528 
Retro-displacement, Alexander's 

operation, 142 

diagnosis of, 133 

menstruation in, 133 

operation for, 142 

pessaries in, 133 

pregnancy and, 130 
Retro-displacements, results of, 131 

symptoms of, 132 

treatment of, 133, 145 

ventro-fixation for, 133 
Retroflexion of uterus, 127 

causes of, 129 
Retroversion of uterus, 127 
causes of, 129 
degrees of, 128 
Rheumatism cause of ovarian disease, 

34o 
Robb's formulae for celloidin, 479 
Room for gynecological operations, 

461 
Round ligament, ligation of, 520 
Round-ligament cysts, 42 
Rubber dam, 480 

gloves, 465 

Salpingitis, 276, 287 

abdominal ostium, closure of, 280 

acute, 277, 288 

adhesions due to, 279, 280 

after endometritis, 288, 299 

catarrhal, 279 

causes of, 276, 279, 287 

celiotomy for, 296, 299, 300 

chronic, 279 

catarrhal, 279 

interstitial, 280 
cystic distention in, 282 
dangers of, 289, 291 
diagnosis of, 295 
fistula in, 290 
hematosalpinx with, 282 
hydrosalpinx with, 282 



Salpingitis, hypertrophy in, 281 
hysterectomy for, 302 
ovarian abscess and, 283 
ovaritis and, 283 
pelvic abscess in, 297 

massage in, 299 
pyosalpinx, 282 

salpingo-odphorectomy for, 302 
septic, 277, 288 
symptoms of, 291 
treatment of, 296, 300 
tubal pregnancy from, 314 
with tubal abscess, 279, 283 
Salpingo-odphorectomy, 504 
adhesions after, 510 
for chronic ovaritis, 344 
for salpingitis, 302 
for uterine fibroid, 252 
link-ligature in, 506 
menopause due to, 535 
menstruation after, 535 
secondary effects of, 535 
sexual emotion after, 536 
Tait knot, 506 
Sarcoma of Fallopian tubes, 313 
of ovary, 391 
of uterus, 15, 225 

age of occurrence, 228 
duration of, 228 
symptoms of, 226 
treatment of, 228 
urethral, 436 
Scissors, Emmet's perineal, 64 
Senile endometritis, 213 
Septic foci, dangers of, 37 

infection of genital tract, 17 
Shock after celiotomy, 498 
Shot-compressor, 66 
Silk, 476 

Sims' curette, 209 
depressor, 29 
position, 31 

topographical changes in, 32 
speculum, 29 

as anal retractor, 33 
vaginal dilator, 416 
Skene's endoscope, 432 
glands, 426 

inflammation of, 429 
installation tube, 173 
reflux catheter, 429 
Smith's pessary, 134 
Sound, urethral, 430 
uterine, 34 

asepsis in use in, 35 

diagnosis between inversion and 

polyp by use of, 268 
precautions in use of, 35 
Speculum, rectal, 7,3 



INDEX. 



547 



Speculum, vaginal, 28 

bivalve, Goodell's, 29 
duck-bill, Sims', 29 
introduction, 29, $$ 
uses, 28, 30, 31 
vesical, 424 
Spencer Wells' forceps, 474 
Sphincter ani, 58 

atrophy and laceration of, 69 
dimple over ends of, 70 
laceration, repair of, 69 
vaginas, 58 
Split cervix, 177 
Sponge-holder, 65 
Sponges in abdominal operations, 474 

sterilization of, 468 
Sprague's sterilizer, 466 
Spurious labor, 321 
Squamous-cell carcinoma of cervix, 

181 
Stem-pessary in anteflexion, 123 
Sterility as result of gonorrhea, 17 
in anteflexion, 122 
in chronic endometritis, 206 
in lacerated cervix, 154 
in salpingitis, 294 
Sterilization, discontinuous, 466 
fractional, 466 
of dressings, 466 
of hands, 465 
of instruments, 466 
of sponges, 468 
of tables, 463 
of water, 467 

personal, for operations, 463 
Sterilizer, Arnold's, 466 

Sprague's, 466 
Stricture, urethral, 430 
Subinvolution as cause of ovarian pro- 
lapse, 336 
of uterus, 215 

endometritis in, 215 
metritis in, 215 

symptoms and treatment of, 216 
of vagina, 92 
Superinvolution of uterus, 217 

amenorrhea in, 217 
Suppressio mensium, 405 
Supra-vaginal cervix, elongation of, 

104 
Sutures, 476, 477 
Syncytioma malignum, 228 
symptoms, 229 
treatment, 229 
Syphilis acquired during examination, 
26 
elephantiasis in, 47 
primary sore on finger of phvsician, 
26 



Sypjiilitic ulceration, diagnosis from 

carcinoma of cervix, 188 
Syringe for cleansing drainage-tube, 

481 

Table for operating, 462 

sterilization of, 463 
Tait knot, 506, 508 
Tait's hemostatic forceps, 474 
Tapping of ovarian cyst, 387, 512, 513 

dangers of, 388 
Temperature after celiotomy, 498 
Tenacula, 27, 64 
Teratoma, 361 
Thomas's pessary, 134 
Through-and-through suture, 491 
Tissue-forceps, 65 
Trachelorrhaphy, 156 
contraindications to, 289 
curetting in, 160 
preparation for, 160 
scissors for, 157 
Transplantation of cancer-cells dur- 
ing hysterectomy, 525 
Trendelenburg position, 462, 510 
Trigone, 436 

mucous membrane of, 437 
Trocar, 476 

Tubal changes in fibroids, 237 
pregnancy, 314 

abdominal enlargement in, 323 
abortion, 316, 318 
amenorrhea in, 326 
ballottement in, 323 
causes of, 314 
classification of, 315 
curettage for diagnosis in, 315 
decidual transformation of endo- 
metrium in, 320 
diagnosis of, 325 
Fallopian tube, changes in, 315 
fetal movements in, 323 
heart-sounds in, 323 
hematoma in, 324 
hemorrhage in, 317 
mammary changes in, 322 
menstruation in, 322 
pain in, 322, 324 
placental hemorrhage during celi- 
otomy for, 329 
polypi as cause of, 314 
rupture in, 316, 317, 324, 327 
secondary rupture, 317 
skin-changes in, 322 
spurious labor in, 321 
symptoms of, 321 
termination of, 310, 3 28 
treatment of, 327 
tubal changes in, 315 



548 



INDEX. 



Tubal pregnancy, uterine changes in, 
316, 320 
vaginal changes in, 322 
varieties of, 314 
Tuberculosis of cervix, 180 
of Fallopian tubes, 306 
chronic diffuse, 309 

fibroid, 309 
diagnosis of, 311 
infection of, 310 
miliary, 308 
primary, 309 
prognosis in, 311 
secondary, 310 
symptoms, 310 
treatment of, 312 
unsuspected, 308 
of ovary, 393 
of uterus, 261 
Tubo-ovarian abscess, 283, 287 
pregnancy, 314. See also Tubal 
pregnancy. 

Ureter, bimanual examination of, 25 

carcinoma of, 185 

introduction of bougies in hysterec- 
tomy, 523 

relations of, 445, 521, 526 
to uterine artery, 504 

vesical orifice of, 437 
Ureteritis, result of cystitis in, 438 
Uretero-vaginal fistula, 421 
Urethra, anatomy of, 426 

cancer of, 436 

caruncle of, 434 

course of, 445 

cysts of, 435 

dilatation of, 433 

prolapse of, 431 

sarcoma of, 436 
Urethral polyp, 435 

sound, 430 

stricture, 430 
Urethritis, 427, 449 
Urethrocele, 434 

Urinary excretion after celiotomy, 436 
Uterine appendages, removal of, 504 

artery, 503 

ligation of, 196, 520, 526 
relations to ureter, 504 

cavity, length of, 34 

cornua, bimanual examination of, 

2 5. 
fibroid, 230 

fibro-myoma, 230 

forceps, 138 

inversion in recurrent fibroid, 227 

involvement in cervical carcinoma, 

185 



Uterine ligaments, action of, 96 

structure of, 96 
myofibroma, 230 
myoma, 230 
polyp, 234 

diagnosis from carcinoma of cer- 
vix, 188 

with inversion, 271 
retro-displacements, parturition as 

cause, 130 
retroflexion, causes of, 129 
sound, 34 

abortion by use of, 35 

asepsis in use of, 35 

dangers of, 35 

in diagnosis between inversion 
and uterine polyp, 268 

precautions in use, 35 
Utero-sacral ligaments, 27, 119 
Uterus, absence of, 396 
adenomyoma of, 257 
anteflexion, 119 

causes of normal, 119 

classification of, 120 

menstruation in, 122 

miscarriage in, 123 

pathological, 120 

pessary in, 123 

pregnancy in, 123 

sterility in, 122 

symptoms of, 122 

treatment of, 123 
axis of, 95 
•bicornis duplex, 396 

unicollis, 397 
bimanual reposition, 135 
carcinoma of, 218 

age of occurrence, 220 

bimanual examination of, 224 

curette, 224 

leucorrhea, 223 

metastasis, 223, 224 

operation for, 224, 225 

pain, 223 

symptoms, 222 
cordiformis, 397 
development, 395 
didelphys, 396 
fibroid tumors of, 236 

intraligamentous, 235 
submucous, 234 
subperitoneal, 233 
fibro-sarcoma of, 227 
instrumental reposition, 136 
inversion of, 264 

diagnosis from uterine polyp, 268 

reposition in, 268 

White's repositor for, 269 
irrigation after curettement, 210 



INDEX. 



549 



Uterus, ligaments of, 95 

mechanism of support, 95, 96 
perforation of, by curette, 210 
position, 94, 119 
prolapse of, 10 1 

amputation of cervix in, 117 

causes of, 97, 98, 102, 108 

colpeurynter in, 118 

cystocele and rectocele in, 107 

diagnosis of, no 

Emmet's operation for, 112 

hysterectomy for, 117 

LeFort's operation, 112 

pessaries in, 118 

pregnancy as cause of, 108 
sequelae of, in 

Sims' operation for, 115 

structural changes in, 106 

symptoms, 108 

treatment, no 

ventro-fixation for, 113 
rectal examination of, 27 
relations of, 119 

to bladder, 94 
removal, 515. See also Hysterec- 
tomy. 
replacement, 135, 136 

contraindications to, 289 
retention in position, 142 
retro-displacement, congenital, 129, 

146 
retroflexion of, 127 
retroversion of, 127 

causes, 129 

degrees, 128 
sarcoma of, 225 

age of occurrence, 228 

duration of life, 228 

symptoms, 225, 226 

treatment, 225 

varieties, 225 
septus, 397 
Skene's glands, 426 
stitching to abdominal wall, 142 
subinvolution of, 215 
superinvolution after amputation of 

cervix, 217 
supra- vaginal amputation, 518, 521 
closure of cervical canal in, 522 
sterilization of cervical canal 
in, 522 
tuberculosis of, 261 
unicornis, 396 
vascular supply of, 437 

Vagina, absence of, 398 
angle of, 60 

anterior wall, length, 60 
atresia, 17, 52 



Vagina, carcinoma of, 52 

cysts of, 51 

development of, 395 

dilator for, Sims', 416 

fibroid tumors of, 52 

furrows of, 61 

incision of, in hysterectomy, 524 

inflammation of, 49 

long axis of, 60 

malformations of, 397 

normal condition of, 96 

ostium of, 57 

posterior wall, length of, 60 

preparation of, for operation, 472 

prolapse of, 75 

sarcoma of, 52 

shape of, 60 

subinvolution of, 92 

sulci of, 60 

unilateral, 398 
Vaginal arteries, 504 

cervix, elongation, 104, 178 

drainage, 480, 487 

examination, 23 
cleansing for, 26 
contraindications to, 28 

hematocolpos, 53, 399 

hysterectomy, 527 

removal of tubes and ovaries, 

pessaries, 133, 138, 140 

retractor, 528 

speculum, 28 

bivalve, Goodell's, 29 
duck-bill, Sims', 29 
uses, 28, 30, 31 

sulci, laceration of, 75 

tumor, 51 
treatment, 52 

wall-depressor, 29, 31, 32 
Vaginismus, 53 
Vaginitis, 49 

adhesive, 51 

dangers of, 50 

emphysematous, 49 

epidemics of, 39 

etiology, 49 

gonorrheal, 453 

granular, 49 

in children, 49 

in exanthemata, 49 

senile, 49 

simple, 49 

symptoms, 50 

treatment, 50, 51 
Ventral hernia, 402 
Ventro-fixation, 142, 143 

in uterine prolapse, 113 
Ventro-suspension, 142, 143 



55Q 



INDEX. 



Ventro-suspension, incision for, 487 
Vermiform appendix, 21 
Vesical applicator, 425 
calculus, 447 

in vesico-vaginal fistula, 416 
probe, 425 
speculum, 424 
triangle, 436 

mucous membrane of, 437 
nerves of, 437 
Vesico-urethral fissure, 431 
Vesico-uterine fistula, 420 
Vesico-vaginal fistula, 412 
and calculus, 416 
kolpokleisis in, 420 
operation for, 417 
treatment, 415 
Vicarious diarrhea, 408 
leucorrhea, 408 
menstruation, 408 
Vomiting after celiotomy, 497 
Vulva, elephantiasis of, 47 
gonorrhea of, 454 
hematoma of, 46 
neoplasms of, 46, 47 
papilloma of, 46 



Vulva, pruritus of, 42 
etiology, 42, 43 
excision of mucous membranes, 

44 
treatment, 43 
varicose tumors of, 46 
Vulvitis, 36 

causes of, 36, 37 
epidemics of, 37 
follicular, 36 

gonorrhea as cause of, 36 
in children, 37 

late manifestations of, 37, 38 
medico-legal examination in, 37 
secondary, 36, 37 
symptoms of, 36 
treatment of, 37 
Vulvo-vaginal glands, cysts of, 40 
inflammation of, 38, 39 

Water after celiotomy, 494 

in gynecological operations, 467 
sterilization of, 467 

Werder's combined hysterectomy, 532 

White's repositor, 270 

Wolffian canal, 52 



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dealing with General Pathology has been most extensively revised, several of the 
important chapters having been practically rewritten. A very useful addition 
is an Appendix treating of th' technic of pathologic methods, giving briefly the 
most important methods at present in use for the study of pathology, including, 
however, only those methods capable of giving satisfactory results. The book 
will be found to maintain fully its popularity. 



PERSONAL AND PRESS OPINIONS 



William H. Welch, M. D., 

Professor of Pathology, Johns Hopkins University, Baltimore, Md. 

" I consider the work abreast of modern pathology, and useful to both students and practi- 
tioners. It presents in a concise and well-considered form the essential facts of general and 
special pathologic anatomy, with more than usual emphasis upon pathologic physiology." 

Ludvig Hektoen, M. D., 

Professor of Pathology, Rush Medical College, Chicago. 

" I regard it as the most serviceable text-book for students on this subject yet written by an 
American author." 

The Lancet, London 

"This volume is intended to present the subject of pathology in as practical a form as pos- 
sible, and more especially from the point of view of the 'clinical pathologist.' These subjects 
have been faithfully carried out, and a valuable text-book is the result. We can most favorably 
recommend it to our readers as a thoroughly practical work on clinical pathology." 



SAUNDERS' BOOKS ON 



GET A • THE NEW 

THE BEST I\ 111 © T 1 C Si II STANDARD 

Illustrated Dictionary 

Recently Issued— New (4th) Edition 



The American Illustrated Medical Dictionary. A new and com- 
plete dictionary of the terms used in Medicine, Surgery, Dentistry, 
Pharmacy, Chemistry, and kindred branches; with over ioo new and 
elaborate tables and many handsome illustrations. By W. A. Newman 
Dorland, M. D., Editor of " The American Pocket Medical Diction- 
ary." Large octavo, nearly 850 pages, bound in full flexible leather. 
Price, $4.50 net; with thumb index, 35.00 net. 

Gives a Maximum Amount of Matter in a Minimum Space, and at the Lowest 

Possible Cost 

WITH 2000 NEW TERMS 

The immediate success of this' work is due to the special features that distin- 
guish it from other books of its kind. It gives a maximum of matter in a mini- 
mum space and at the lowest possible cost. Though it is practically unabridged, 
yet by the use of thin bible paper and flexible morocco binding it is only 1% 
inches thick. The result is a truly luxurious specimen of book-making. In this 
new edition the book has been thoroughly revised, and upward of two thousand 
new terms that have appeared in recent medical literature have been added, thus 
bringing the book absolutely up to date. The book contains hundreds of terms 
not to be found in any other dictionary, over 100 original tables, and many hand- 
some illustrations, a number in colors. 



PERSONAL OPINIONS 



Howard A. Kelly, M. D., 

Professor of Gynecology, Johns Hopkins University , Baltimore. 

" Dr. Dorland's dictionary is admirable. It is so well gotten up and of such convenient 
size. No errors have been found in my use of it." 

J. Collins Warren, M.D., LL.D., F.R.C.S. (Hon.) 

Professor of Surgery, Harvard Medical School. 

" I regard it as a valuable aid to my medical literary work. It is very complete and of 
convenient size to handle comfortably. I use it in preference to any other." 



EMBRYOLOGY. 



Heisler's 
Text-Book qf Embryology 

Recently Issued— The New (3d) Edition 



A Text=Book of Embryology. By John C. Heisler, M.D., Pro- 
fessor of Anatomy in the Medico-Chirurgical College, Philadelphia. 
Octavo volume of 435 pages, with 212 illustrations, 32 of them in 
colors. Cloth, $3.00 net. 

WITH 212 ILLUSTRATIONS, 32 IN COLORS 

The fact of embryology having acquired in recent years such great interest 
in connection with the teaching and with the proper comprehension of human 
anatomy, it is of first importance to the student of medicine that a concise and 
yet sufficiently full text-book upon the subject be available. This new edition 
represents all the latest advances recently made in the science of embryology. 
Many portions have been entirely rewritten, and a great deal of new and impor- 
tant matter added. A number of new illustrations have also been introduced and 
these will prove very valuable. The previous editions of this work filled a gap 
most admirably, and this new edition will undoubtedly maintain the reputation 
already won. Heisler's Embryology has become a standard work. 



PERSONAL AND PRESS OPINIONS 



C. Carl Huber, M. D., 

Professor of Histology and Embryology, University of Michigan, Ann Arbor. 

" I find the second edition of ' A Text-Book of Embryology' by Dr. Heisler an improve- 
ment on the first. The figures added increase greatly the value of the work. I am again 
recommending it to our students." 

William Wathen, M. D., 

Professor of Obstetrics, Abdominal Surgery, and Gynecology, and Dean, Kentucky School of 

Medicine, Louisville, Ky. 
" It is systematic, scientific, full of simplicity, and just such a work as a medical student 
will be able to comprehend." 

Birmingham Medical Review, England 

" We can most confidently recommend Dr. Heisler's book to the student of biology or 
medicine for his careful study, if his aim be to acquire a sound and practical acquaintance with 
the subject of embryology." 



SAUNDERS' BOOKS ON 



Mallory and Wright's 
Pathologic Technique 

Just Issued — Fourth Edition, Revised and Enlarged 



Pathologic Technique. A Practical Manual for Workers in Patho- 
logic Histology, including Directions for the Performance of Autopsies 
and for Clinical Diagnosis by Laboratory Methods. By Frank B. 
Mallory, M. D., Associate Professor of Pathology, Harvard Univer- 
sity'; and James H. Wright, M. D., Director of the Clinico-Pathologic 
Laboratories, Massachusetts General Hospital. Octavo of 500 pages, 
with 155 illustrations. Cloth, $3.00 net. 

WITH CHAPTERS ON POST-MORTEM TECHNIQUE AND AUTOPSIES 

In revising the book for the new edition the authors have kept in view the 
needs of the laboratory worker, whether student, practitioner, or pathologist, for 
a practical manual of histologic and bacteriologic methods in the study of patho- 
logic material. Many parts have been rewritten, many new methods have been 
added, and the number of illustrations has been considerably increased. Among 
the many changes and additions may be mentioned the amplification of the de- 
scription of the Parasite of Actinomycosis and the insertion of descriptions of the 
Bacillus of Bubonic Plague, of the Parasite of Mycetoma, and Wright's methods 
for the cultivation of Anaerobic Bacteria. There have also been added new 
staining methods for elastic tissue by Weigert, for bone by Schmorl, and for con- 
nective tissue by Mallory. The new edition of this valuable work keeps pace 
with the great advances made in pathology, and will continue to be a most useful 
laboratory and post-mortem guide, full of practical information. 



PERSONAL AND PRESS OPINIONS 



Wm. H. Welch, M. D., 

Professor of Pathology, Johiis Hopki7is University , Baltimore. 

" I have been looking forward to the publication of this book, and I am glad to say that I 
find it a most useful laboratory and post-mortem guide, full of practical information and well 
up to date." 

Boston Medical and Surgical Journal 

" This manual, since its first appearance, has been recognized as the standard guide in patho- 
logical technique, and has become well-nigh indispensable to the laboratory worker." 

Journal of the American Medical Association 

" One of the most complete works on the subject, and one which should be in the library 
of every physician who hopes to keep pace with the great advances made in pathology." 



HISTOLOGY. 



Bohm, Davidoff, and 
Huber's Histology 



A Text=Book of Human Histology. Including Microscopic Tech- 
nics By Dr. A. A. Bohm and Dr. M. von Davidoff, of Munich, and 
G. Garl Huber, M. D., Professor of Histology and Embryology in 
the University of Michigan, Ann Arbor. Handsome octavo of 528 
pages, with 361 beautiful original illustrations. Flexible cloth, $3.50 net. 

RECENTLY ISSUED— NEW (2d) EDITION, ENLARGED 

The work of Drs. Bohm and Davidoff is well known in the German edition, 
and has been considered one of the most practically useful books on the subject 
of Human Histology. This second edition has been in great part rewritten and 
very much enlarged by Dr. Huber, who has also added over one hundred origi- 
nal illustrations. Dr. Huber's extensive additions have rendered the work the 
most complete students' text-book on Histology in existence. 

Boston Medical and Surgical Journal 

" Is unquestionably a text-book of the first rank, having been carefully written by thorough 
masters of the subject, and in certain directions it is much superior to any other histological 
manual." 



DrewV 
Invertebrate Zoology 

A Laboratory Manual of Invertebrate Zoology. By Gilman A. 
Drew, Ph.D., Professor of Biology at the University of Maine. With the 
aid of Members of the Zoological Staff of Instructors of the Marine Biolog- 
ical Laboratory, Woods Holl, Mass. i2mo of 200 pages. Cloth, $1.25 net. 

RECENTLY ISSUED 

The subject is presented in a logical way, and the type method of study has 
been followed, as this method has been the prevailing one for many years. 

Prof. Allison A. Smyth, Jr., Virginia Polytechnic Institute 

" I think it is the best laboratory manual of zoology I have yet seen. The large number 
of forms dealt with makes the work applicable to almost any locality." 



SAUNDERS' BOOKS ON 



McFarland's 
Pathogenic Bacteria 

The New (5th) Edition, Revised 



A Text=Book Upon the Pathogenic Bacteria. By Joseph McFar- 
land, M. D., Professor of Pathology and Bacteriology in the Medico- 
Chirurgical College of Philadelphia, Pathologist to the Medico-Chirur- 
gical Hospital, Philadelphia, etc. Octavo volume of 647 pages, finely 
illustrated. Cloth, $3.50 net. 

RECENTLY ISSUED 

This book gives a concise account of the technical procedures necessary in the 
study of bacteriology, a brief description of the life-history of the important patho- 
genic bacteria, and sufficient description of the pathologic lesions accompanying 
the micro-organismal invasions to give an idea of the origin of symptoms and the 
causes of death. The illustrations are mainly reproductions of the best the world 
affords, and are beautifully executed. In this edition the entire work has been 
practically rewritten, old matter eliminated, and much new matter inserted. 

H. B. Anderson, M. D., 

Professor of Pathology and Bacteriology, Trinity Medical College, Toronto. 
" The book is a satisfactory one, and I shall take pleasure in recommending it to the students 
of Trinity College." 

The Lancet, London 

" It is excellently adapted for the medical students and practitioners for whom it is avowedly 
written. . . . The descriptions given are accurate and readable." 



Hill's Histology and Organography 

A Manual of Histology and Organography. By Charles Hill, 
M. D., Professor of Histology and Embryology, Northwestern Univer- 
sity, Chicago. i2mo of 463 pages, 313 illustrations. Flexible leather, 
$2.00 net. 

RECENTLY ISSUED 

Dr. Hill's fifteen years' experience as a teacher of histology has enabled him to 
present a work characterized by clearness and brevity of style and a completeness 
of discussion rarely met in a book of its pretensions. Particular consideration is 
given the mouth and teeth ; and illustrations are most freely used. 



BACTERIOLOGY AND PATHOLOGY. 



Eyre's 
Bacteriologic Technique 



The Elements of Bacteriologic Technique. A Laboratoiy Guide 
for the Medical, Dental, and Technical Student. By J. W. H. Eyre, 
M. D., F. R. S. Edin., Bacteriologist to Guy's Hospital, London, and 
Lecturer on Bacteriology at the Medical and Dental Schools, etc. 
Octavo volume of 375 pages, with 170 illustrations. Cloth, $2.50 net. 

FOR MEDICAL, DENTAL, AND TECHNICAL STUDENTS 

This book presents, concisely yet clearly, the various methods at present in 
use for the study of bacteria, and elucidates such points in their life-histories as 
are debatable or still undetermined. It includes only those methods that are 
capable of giving satisfactory results even in the hands of beginners. The illus- 
trations are numerous and practical. The work is designed with the needs of the 
technical student generally constantly in view. 

The Lancet, London 

" Stamped throughout with evidence that the writer is a practical teacher, and the directions 
are more clearly given . . . than in any previous work." 

Warren's 

Pathology and Therapeutics 

Surgical Pathology and Therapeutics. By John Collins Warren, 
M. D., LL.D., F. R. C. S. (Hon.), Professor of Surgery, Harvard Medical 
School. Octavo, 873 pages, 136 relief and lithographic illustrations, 33 
in colors. With an Appendix on Scientific Aids to Surgical Diagnosis 
and a series of articles on Regional Bacteriology. Cloth, $5.00 net; 
Sheep or Half Morocco, $6.50 net. 

SECOND EDITION, WITH AN APPENDIX 

In the second edition of this book all the important changes have been em- 
bodied in a new Appendix. In addition to an enumeration of the scientific aids to 
surgical diagnosis there is presented a series of sections on regional bacteriology, 
in which are given a description of the flora of the affected part, and the general 
principles of treating the affections they produce. 

Roswell Park, M. D., 

In the Harvard Graduate Magazine. 

" I think it is the most creditable book on surgical pathologv, and the most beautiful medical 
illustration of the bookmakers' art that has ever been issued from the American press." 



SAUNDERS' BOOKS ON 



Dtirck and Hektoen's 

Special Pathologic Histology 



Atlas and Epitome of Special Pathologic Histology. By Dr. H. 

Durck, of Munich. Edited, with additions, by Ludvig Hektoen, M. D., 
Professor of Pathology, Rush Medical College, Chicago. In two parts. 
Part I. — Circulatory, Respiratory, and Gastro-intestinal Tracts. 120 
colored figures on 62 plates, and 158 pages of text. Part II. — Liver, 
Urinary and Sexual Organs, Nervous System, Skin, Muscles, and 
Bones. 123 colored figures on 60 plates, and 192 pages of text. Per 
part : Cloth, $3.00 net. In Saunders' Hand-Atlas Series. 

The great value of these plates is that they represent in the exact colors the effect 
of the stains, which is of such great importance for the differentiation of tissue. 
The text portion of the book is admirable, and, while brief, it is entirely satisfac- 
tory in that the leading facts are stated, and so stated that the reader feels he has 
grasped the subject extensively. 

William H. Welch, M. D., 

Professor of Pathology, Johns Hopkiifs University, Balti?nore. 

"I consider Diirck's 'Atlas of Special Pathologic Histology,' edited by Hektoen, a very- 
useful book for students and others. The plates are admirable." 

Sobotta and Htiber's 
Human Histology 

Atlas and Epitome of Human Histology. By Privatdocent Dr. 
J. Sobotta, of Wiirzburg. Edited, with additions, by G. Carl Huber, 
M. D., Professor of Histology and Embryology in the University of 
Michigan, Ann Arbor. With 214 colored figures on 80 plates, 68 
text-illustrations, and 248 pages of text. Cloth, $4.50 net. In 
Saunders' Hand- Atlas Series. 

INCLUDING MICROSCOPIC ANATOMY 

The work combines an abundance of well-chosen and most accurate illustra- 
tions, with a concise text, and in such a manner as to make it both atlas and text- 
book. The great majority of the illustrations were made from sections prepared 
from human tissues, and always from fresh and in every respect normal specimens. 
The colored lithographic plates have been produced with the aid of over thirty colors. 

Boston Medical and Surgical Journal 

" In color and proportion they are characterized by gratifying accuracy and lithographic 
beauty." 



PHYSIOLOGY. 13 



American Text- Book of Physiology 



American Text=Book of Physiology. In two volumes. Edited by 
William H. Howell, Ph.D., M. D., Professor of Physiology in the 
Johns Hopkins University, Baltimore, Md. Two royal octavo volumes 
of about 600 pages each, fully illustrated. Per volume : Cloth, $3.00 
net ; Sheep or Half Morocco, $4.25 net. 

SECOND EDITION, REVISED AND ENLARGED 

Even in the short time that has elapsed since the first edition of this work 
there has been much progress in Physiology, and in this edition the book has been 
thoroughly revised to keep pace with this progress. The chapter upon the Cen- 
tral Nervous System has been entirely rewritten. A section on Physical Chem- 
istry forms a valuable addition, since these views are taking a large part in current 
■discussion in physiologic and medical literature. 

The Medical News 

" The work will stand as a work of reference on physiology. To him who desires to know 
the status of modern physiology, who expects to obtain suggestions as to further physiologic 
inquiry, we know of none in English which so eminently meets such a demand." 

Stewart's Physiology 



A Manual of Physiology, with Practical Exercises. For Students 
and Practitioners. By G. N. Stewart, M. A., M. D., D. Sc, Professor 
of Physiology in the University of Chicago, Chicago. Octavo 
volume of 911 pages, with 395 text -illustrations and colored plates. 

Cloth, $4.00 net. 

RECENTLY ISSUED— NEW (5th) EDITION 



This work is written in a plain and attractive style that renders it particularly 
suited to the needs of students. The systematic portion is so treated that it can 
be used independently of the practical exercises. In the present edition a con- 
siderable amount of new matter has been added, especially to the chapters on 
Blood, Digestion, and the Central Nervous System, 

Philadelphia Medical Journal 

" Those familiar with the attainments of Prof. Stewart as an original investigator, as a 
teacher and a writer, need no assurance that in this volume he has presented in a terse, concise, 
accurate manner the essential and best established facts of physiology in a most attractive 
manner." 



i 4 SAUNDERS' BOOKS ON 



Levy and Klemperer's 
Clinical Bacteriology 

The Elements of Clinical Bacteriology. By Drs. Ernst Levy and 
Felix Klemperer, of the University of Strasburg. Translated and 
edited by Augustus A. Eshner, M. D., Professor of Clinical Medicine, 
Philadelphia Polyclinic. Octavo volume of 440 pages, fully illustrated. 
Cloth, $2.50 net. 

S. Solis-Cohen, M. D., 

Professor of Clinical Medicine, Jefferson Medical College, Philadelphia. 

" I consider it an excellent book. I have recommended it in speaking to my students." 

Lehmann, Neumann, and 
Weaver's Bacteriology 

Atlas and Epitome of Bacteriology : including a Text-Book of 
Special Bacteriologic Diagnosis. By Prof. Dr. K. B. Lehmann 
and Dr. R. O. Neumann, of Wiirzburg. From the Second Revised and 
Enlarged German Edition. Edited, with additions, by G. H. Weaver, 
M. D., Assistant Professor of Pathology and Bacteriology, Rush Medical 
College, Chicago. In two parts. Part I. — 632 colored figures on 69 
lithographic plates. Part II. — 511 pages of text, illustrated. Per part: 
Cloth, $2.50 net. In Saunders' Hand- Atlas Series. 

Lewis' Anatomy and Physi- 
ology for Nurses 

Anatomy and Physiology for Nurses. By LeRoy Lewis, M.D., 
Surgeon to and Lecturer on Anatomy and Physiology for Nurses at 
the Lewis Hospital, Bay City, Michigan. i2mo of 347 pages, with 
146 illustrations. Cloth, #1.75 net. 

JUST ISSUED— NEW (2d) EDITION 

Nurses Journal of the Pacific Coast 

" It is not in any sense rudimentary, but comprehensive in its treatment of the subjects in 
hand." 



PATHOLOGY, BACTERIOLOGY, AND PHYSIOLOGY. 15 

Senil'S Tumors Second Revised Edition 

Pathology and Surgical Treatment of Tumors. By Nicholas 
Senn, M. D., Ph. D., LL.D., Professor of Surgery, Rush Medical Col- 
lege, Chicago. Handsome octavo, 718 pages, with 478 engravings, 
including 12 full-page colored plates. Cloth, $5.00 net; Sheep or Half 
Morocco, I6.50 net. 

" The most exhaustive of any recent book in English on this subject. It is well illus- 
trated, and will doubtless remain as the principal monograph on the subject in our 
language for some years." — Journal of the American Medical Association. 

Stoney's Bacteriology and Technic ,j£3)£Ei 

Bacteriology and Surgical Technic for Nurses. By Emily M. A. 
Stoney, Superintendent, Carney Hospital, Mass. Revised by Frederic 
R. Griffith, M.D., Surgeon, N. Y. i2mo of 278 pages, illustrated. 
#1.50 net. 

"These subjects are treated most accurately and up to date, without the superfluous 
reading which is so often employed. . . . Nurses will find this book of the greatest value." 
— The Trained Nurse and Hospital Review. 

Clarkson's Histology 

A Text-Book of Histology. Descriptive and Practical. For the 
Use of Students. By Arthur Clarkson, M. B., C. M. Edin., formerly 
Demonstrator of Physiology in the Owen's College, Manchester, Eng- 
land. Octavo, 554 pages, with 174 colored original illustrations. 
Cloth, $4.00 net. 

" The volume in the hands of students will greatly aid in the comprehension of a sub- 
ject which in most instances is found rather difficult. . . . The work must be considered 
a valuable addition to the list of available text-books, and is to be highly recommended." 
— New York Medical Journal. 

Gorham's Bacteriology 

A Laboratory Course in Bacteriology. For the Use of Medical, 
Agricultural, and Industrial Students. By Frederic P. Gorham, A. M., 
Associate Professor of Biology in Brown University, Providence, R. L, 
etc. i2mo of 192 pages, with 97 illustrations. Cloth, $1.25 net. 

" One of the best students' laboratory guides to the study of bacteriology on the mar- 
ket. . . . The technic is thoroughly modern and amply sufficient for all practical pur- 
poses." — American Journal of the Medical Sciences. 

Raymond's Physiology ^S, 

Human Physiology. By Joseph H. Raymond, A. M., M. D., Pro- 
fessor of Physiology and Hygiene, Long Island College Hospital, New 
York. Octavo of 685 pages, with 444 illustrations. Cloth, S3. 50 net. 

" The book is well gotten up and well printed, and may be regarded as a trustworthy 
guide for the student and a useful work of reference for the general practitioner. The 
illustrations are numerous and are well executed." — The Lancet, London. 



16 BACTERIOLOGY, PHYSIOLOGY, AND HISTOLOGY. 

Ball's Bacteriology Recently Issued— Fifth Edition, Revised 

Essentials of Bacteriology : being a concise and systematic intro- 
duction to the Study of Micro-organisms. By M. V. Ball, M. D., Late 
Bacteriologist to St. Agnes' Hospital, Philadelphia. i2mo of 236 pages, 
with 96 illustrations, some in colors, and 5 plates. Cloth, #1.00 net. In 
Saunders' Question- Compend Series. 

" The technic with regard to media, staining, mounting, and the like is culled from the 
latest authoritative works." — The Medical Times, New York. 

n 1, 1,, i*k« • 1 * Recently Issued 

Blldgett S PhySlOlOgy New (2d) Edition 

Essentials of Physiology. Prepared especially for Students of Medi- 
cine, and arranged with questions following each chapter. By Sidney 
P. Budgett, M. D., Professor of Physiology, Medical Department of 
Washington University, St. Louis. i6mo volume of 233 pages, finely 
illustrated with many full-page half-tones. Cloth, #1.00 net. In 
Saunders' Question- Compend Series. 

"He has an excellent conception of his subject. . . It- is one of the most satisfactory 
books of this class" — University of Pennsylvania Medical Bulletin. 
* 9 u- a 1 ^ Recently Issued 

Leroy s Histology New (3d) Edition 

Essentials of Histology. By Louis Leroy, M. D., Professor of 
Histology and Pathology, Vanderbilt University, Nashville, Tennessee. 
i2mo, 263 pages, with 92 original illustrations. Cloth, $1.00 net. In 
Saunders'' Question- Compend Series. 

" The work in its present form stands as a model of what a student's aid should be ; and 
we unhesitatingly say that the practitioner as well would find a glance through the book 
of lasting benefit." — The Medical World, Philadelphia. 

Bastin's Botany 

Laboratory Exercises in Botany. By the late Edson S. Bastin, 
M. A. Octavo, 536 pages, with 87 plates. Cloth, $2.00 net. 

Barton and Wells* Medical Thesaurus 

A Thesaurus of Medical Words and Phrases. By Wilfred M. 
Barton, M. D., Assistant Professor of Materia Medica and Therapeutics, 
and Walter A. Wells, M.D., Demonstrator of Laryngology, Georgetown 
University, Washington, D. C. i2mo, 534 pages. Flexible leather, 
$2.50 net; thumb indexed, $3.00 net. 
A «, t\ 1 l r^» 1* Fiiih Revised Edition 

American Pocket Dictionary Recently issued 

Dorland's Pocket Medical Dictionary. Edited by W. A. New- 
man Dorland, M. D., Assistant Obstetrician to the Hospital of the 
University of Pennsylvania. Containing the pronunciation and defini- 
tion of the principal words used in medicine and kindred sciences, with 
64 extensive tables. Handsomely bound in flexible leather, with gold 
edges, $1.00 net; with patent thumb index, $1.25 net. 

" I can recommend it to our students without reserve." — J. H. HOLLAND, M. D., 
of the Jefferson Medical College, Philadelphia. 



SEP 9 1903 



/ 



